SexualHealthToolkit2010BW PDF

Sexual Health
An Adolescent Provider Toolkit
Illustrations by Jordan Zioni, 17

HOW TO OBTAIN A COPY The Sexual Health Module of the Adolescent Provider Toolkit can be downloaded for free from
the following website:
OF THIS TOOLKIT
Adolescent Health Working Group www.ahwg.net
Please visit our website for information on purchasing hard copies of the Sexual Health Module.
Additional AHWG materials including Chinese and Spanish handouts for youth and parents/care-
givers are available for free download.
ADOLESCENT HEALTH The Adolescent Health Working Group (AHWG) was formed in 1996 by a group of adolescent health
providers and advocates concerned about the lack of age-appropriate health services for young people
WORKING GROUP in the city of San Francisco. Today, the AHWG remains the only group of its kind in San Francisco. The
AHWGs vision is that all youth have unimpeded access to high quality, culturally competent, youth
friendly health services. The AHWGs mission is to support and strengthen the network of providers work-
ing to improve adolescent health. The AHWG works to fulfill its vision and mission through the following
core functions: 1) develop tools and trainings that increase providers capacity to effectively serve youth,
2) advocate for policies that increase access to care and utilization of services, and 3) convene stakehold-
ers and coordinate linkages across systems to improve information sharing, networking, and referrals for
youth services.
SUGGESTED CITATION Monasterio E, Combs N, Warner L, Larsen-Fleming M, St. Andrews A, (2010). Sexual Health: An Ado-
lescent Provider Toolkit. San Francisco, CA: Adolescent Health Working Group, San Francisco.
Adolescent Health Working Group
San Francisco, CA
Dear Colleagues:
We are pleased to present you with the new Sexual Health Module of the Adolescent Provider Toolkit series. The production of the
new Sexual Health Module was made possible through the generous support of the San Francisco Department of Children, Youth,
and Their Families, and through the UCSF University Community Partnership program.
The new Sexual Health Module is an updated and expanded version of the 2003 Sexual Health-CA Version. The new module
champions a paradigm shift from a deficit/risk based perspective to one that embraces adolescent sexuality as positive and norma-
tive in this stage of development. This comprehensive guide:
Focuses on healthy sexuality and healthy relationships.
Integrates information regarding the sexual health of all young men and women, LGBT youth, and youth with dis-
abilities.
Is designed for primary care providers and is applicable to many others including school-based and youth program
providers.
Is written from a national perspective.
Is updated with links to the most current evidence based research.
Includes many unique resources in the format of handouts for youth and families.
Designed for busy providers, the new Sexual Health Module includes materials that you are free to copy and distribute to your
colleagues, adolescent patients, and their parents/caregivers. The new Sexual Health Module is not intended to replace clinical
practice protocols. It does provide evidence based practice guidelines to enhance providers ability to meet the sexual health needs
of adolescents. This module includes:
Practice readiness tools.
Screening, assessment, and referral tools such as taking a client-centered sexual health history and screening for
sexual dysfunction.
Resource sheets on various sexual issues including menstrual suppression and male involvement.
Health education handouts for teens and their parents/caregivers on topics including sex and technology and safer sex
toy use.
Online resources and hotlines.
We did not repeat information/tools that are included elsewhere in the Adolescent Provider Toolkit series. General screening and
counseling techniques can be found in the Adolescent Health Care 101 Module. Information and treatment algorithms on Cali-
fornia specific minor consent and confidentiality laws can be found in the Understanding Minor Consent and Confidentiality in
CA Module. We have also opted to refer the reader to regularly updated website for information that changes frequently such as
treatment protocols for STIs, etc.
We encourage you to visit our website, www.ahwg.net, for free downloads of the entire Adolescent Health Toolkit series, includ-
ing health education handouts for youth and parents/caregivers available in Chinese and Spanish. We hope the Adolescent
Provider Toolkit series will be a useful resource for you as you improve the health of adolescents.
Regards,
Erica Monasterio, MN, FNP

Alicia St. Andrews, MPH
Natalie Combs
ACKNOWLEDGEMENTS
The Adolescent Health Working Group has so many people to thank for their generous contributions of time,
energy, expertise, encouragement, and financial support. The Sexual Health Module of the Adolescent Provider
Toolkit has been made possible due to every individual and organization mentioned below. We are incredible
grateful to you.
The Adolescent Provider Toolkit Advisory Council

Alicia St. Andrews, MPH Adolescent Health Working Group
Amy Schalet, PhD University of Massachusetts, Amherst, Department of Sociology
Arik Marcell, MD, MPH Johns Hopkins University, Division of General Pediatrics and Adolescent Medicine
Carla Valdez, MPH Planned Parenthood of Los Angeles
David Bell, MD, MPH Columbia University, Mailman School of Public Health
Erica Monasterio, MN, FNP University of California San Francisco, Division of Adolescent Medicine
Jeff Klausner, MD, MPH San Francisco Department of Health, STD Prevention and Control Services
Kaiyti Duffy, MPH PRCH, Physicians for Reproductive Choice
Leah Warner, RN, MPH University of California San Francisco
Libby Benedict PRCH, Physicians for Reproductive Choice
Mara Larsen-Fleming, MPP, MPH Adolescent Health Working Group
Natalie Combs Adolescent Health Working Group
Paul Gibson, MS, MPH California Department of Public Health, STD Control Branch
Renata Arrington-Sanders, MD, MPH Johns Hopkins University, Division of General Pediatrics & Adolescent Medicine
Tonya Chaffee, MD, MPH University of California San Francisco, Department of Pediatrics
ORIGINAL AUTHORS
Guided by the expertise of the first Adolescent Sexual Health Advisory Toolkit Council, we would like to acknowledge the original authors
of the Sexual Health Toolkit Module: Allison Young, Janet Shalwitz, MD, Sara Pollock and Marlo Simmons, MPH.
Youth Focus Group Participants

Alameda High School Peer Health Educators, Cole Street Youth Clinic Peer Educators, Students from LAUSD Taft High School courtesy
of Bridget Brownell.
OTHER CONTRIBUTORS/REVIEWERS
Amal Kouttab, MA (SFWAR), Carnelius Quinn (Health Initiatives for Youth), Charlie Glickman, PhD (Good Vibrations), Deb Levine, MA
(ISIS, Inc.), Heather Fels (University of California San Francisco), Janet Shalwitz, MD (Adolescent Health Working Group), Kara Rothen-
berg, Rebecca Gudeman, JD, MA (National Center for Youth Law), Rose Afriyie (Adolescent Health Working Group), Tina Mahle (Health
Initiatives for Youth), Urooj Arshad (Advocates for Youth).
Financial Supporters/Fiscal Sponsor

San Francisco Department of Children, Youth, and Their Families, San Francisco Maternal, Child, and Adolescent Health Department,
the San Francisco Foundation, UCSF University Community Partnerships, The Yen Chuang Foundation, and our fiscal sponsor, the Tides
Center.
Special mention goes to Amy Schalet, Arik Marcell, and Carla Valdez who contributed their many gifts of guidance,
expertise, wisdom, and encouragement to the redesign and development of the updated edition of the Sexual Health
Module of the Adolescent Provider Toolkit.
Module Three: SEXUAL HEALTH
A. FOR PROVIDERS/CLINICS Are You Prepared to Address Adolescent Sexual Health?....................................................C-2
1. Practice Readiness Adolescent Sexual Development..........................................................................................C-3
Provider-Youth Communication...........................................................................................C-5
The Role of Providers in Parent-Child Communication.......................................................C-7
Minor Consent and Confidentiality.......................................................................................C-8
Healthy Relationships...........................................................................................................C-9
Sexual Decision-Making.....................................................................................................C-10
Male Involvement...............................................................................................................C-11
2. Screening, Assessment, Taking a Client-Centered Sexual History............................................................................C-13

and Referrals STI Screening and Treatment..............................................................................................C-16
HIV Testing and Counseling...............................................................................................C-18
Human Papillomavirus (HPV) Related Cancers.................................................................C-20
Things to Consider When Prescribing Birth Control..........................................................C-22
Quick Start Algorithm.........................................................................................................C-24
Emergency Contraception...................................................................................................C-26
Pregnancy Test Counseling.................................................................................................C-28
Adolescent Relationship Violence (ARV)...........................................................................C-30
Sexual Assault.....................................................................................................................C-33
Sexual Dysfunction.............................................................................................................C-34
3. Resources Counseling Youth About Sexual Function and Pleasure.....................................................C-36
Safer Sex and Lubrication...................................................................................................C-37
Safer Sex Toy Use...............................................................................................................C-38
Pregnancy Prevention Options............................................................................................C-39
Menstrual Suppression........................................................................................................C-41
Establishing Paternity and Paternity Laws..........................................................................C-43
HPV Vaccine.......................................................................................................................C-44
B. FOR YOUTH Sex, Virginity & Abstinence................................................................................................C-45

Use these handouts as a guide Having Sex on Your Own Terms.........................................................................................C-46
for counseling your teen Healthy Relationships.........................................................................................................C-47
The Relationship Spectrum.................................................................................................C-48
patients.
Love Shouldnt Hurt...........................................................................................................C-49
Wetter Makes It Better........................................................................................................C-50
Be Safe With Sex Toys........................................................................................................C-51
Sex, Technology & You......................................................................................................C-52
Am I Normal? A Tour of The Female Genitals..................................................................C-53
Am I Normal? A Tour of Male Genitals.............................................................................C-54
What to Expect at Your First Womens Health Exam.....................................................C-55
What to Expect at Your First Mens Health Exam..........................................................C-56
Your Safer Sex Options: Preventing Against Pregnancy and STIs.....................................C-57
A Teens Guide to Sexually Transmitted Diseases and Other Infections............................C-59
Genital Warts and HPV-Related Cancer..............................................................................C-61
What You Need To Know About Condoms........................................................................C-62
What You Need To Know About Female AKA Insertive Condoms...............................C-63
Do I Need a Period Every Month?......................................................................................C-64
Im Pregnant, What Should I Do?.......................................................................................C-65
C. FOR PARENTS/ How to Talk with Your Children and Teens about Healthy Relationships..........................C-66
CAREGIVERS Should I Worry About My Teen?........................................................................................C-67
Use these handouts as a guide Parent-Child Communication.............................................................................................C-68
for counseling parents/care- Sex, Technology & Your Teen............................................................................................C-69
What Parents of Preteens/Adolescents Should Know About the HPV Vaccine.................C-70
givers of your teen patients.
Supporting Your Pregnant and Parenting Teen...................................................................C-71
D. INTERNET RESOURCES Click on This!......................................................................................................................C-72
For Providers: practice readiness
Are You Prepared to Address Adolescent Sexual Health?
Creating a safe, non-judgmental, and supportive environment can help teens feel more comfortable sharing personal
information. There are many things that can be done to ensure that your practice is youth friendly. Here are some
questions to consider as your read through Sexual Health Module of the Adolescent Provider Toolkit.
? Does your office/clinic have ? Are you...
Information on where and how to access condoms? Aware of your own biases toward sexual health and
While all clinic settings may not be appropriate for how your own experiences have shaped your opinions
displays, having a small sign near the intake area is toward sexually active adolescents?
recommended. Confident, comfortable, and non-judgmental when
Teen-friendly sexual health education materials with addressing adolescent sexuality?
age-appropriate language in your waiting room? Prepared to take a strengths-based approach when
Do these materials contain positive imagery of teen working with youth?
relationships which do not portray sex only in terms
Aware of the characteristics/features of positive
of the risks and negative consequences? Are your
adolescent sexual development and relationships?
educational materials inclusive of a diverse audience
including LGBT youth and youth with disabilities? Ready to provide medically accurate information
about sexual and reproductive health while
Confidentiality policies posted in areas that can be
also emphasizing the importance of healthy
viewed by both patients and their families?
relationships?
Gender inclusive language on intake/history forms and
Familiar with the legal and confidentiality issues
questionnaires?
dealing with teen sexual activity and reproductive
A procedure for dealing with emergency and crisis health services including access to birth control
situations including rape, sexual assault, and intimate options, STI testing, abortion, sexual assault services;
partner violence? parent/caregiver involvement; and releasing medical
A policy regarding teens scheduling their own records?
appointments? Not all health services require consent
from the parent/caregiver.
Policies regarding talking to a teen alone without his/
Providers role in providing adequate care
her parent/caregiver?
for adolescents:
Financing options for teens accessing confidential
services under minor consent? Make every interaction an opportunity
Clinic/practice hours that are convenient for teens? Support healthy relationships
A network of referrals for adolescent-friendly providers Provide a framework for positive
? in the area? adolescent sexual development
Is your staff Promote health and
Friendly and welcoming toward teen patients? reduce risk
Knowledgeable about the laws of minor consent and
confidentiality and consistent in upholding those laws?
Aware of privacy concerns when adolescents check in?
Careful to avoid making assumptions about gender or
sexual orientation?
Ready to maintain sensitivity for the age, race, ethnicity,
gender, sexual orientation, disability, family structure,
and lifestyle choices of your patients and their loved
ones?
Sources:
1) California Adolescent Sexual Health Work Group (ASHWG). Core Competencies for Providers of Adolescent Sexual and Reproductive Health Programs/
Services. Februry, 2007.
2) Shalwitz J, Sang T, Combs N, Davis K, Bushman D, Payne B. Behavioral Health: An Adolescent Provider Toolkit. Adolescent Health Working Group.
2007: D-5. http://ahwg.net/resources/toolkit.htm.
3) Christner J, Davis P, Rosen D. Office-Based Interventions to Promote Healthy Sexual Behavior. Adol Med: State of the Art Reviews. 2007; 15(544-557).
Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

For Providers: Practice Readiness
Adolescent Sexual Development
STAGE FACTS TIPS

Puberty/Concern with body changes and Begin discussing healthy relationships using
privacy. examples from friendships or concepts such
Development of first crush as a milestone to as, what are you looking for in a friend?
sexual orientation. Focus on current issues facing the teen instead
Concrete thinking, but beginning to explore of future possibilities. Relate decision-
new ability to think abstractly. making techniques to everyday situations
EARLY Sexual fantasies are common.
instead of having him/her visualize what may
ADOLESCENCE happen in the future. Avoid asking questions
Masturbation is common. framed with why.
Females: 9-13 years Movement towards defining sexual identity. Use health education materials with lots of
Males: 11-15 years Sexual intercourse is not common. 4.9% of pictures and simple explanations. Typically,
high school females and 13.5% of high school males are not receiving as much information
males had first intercourse before the age of 13.1 about puberty and body development as girls
at this age.
Focus on issues that most concern this age
group (weight gain, acne, physical changes).
Increasing concern with appearance. Listen more and talk less.

Peer influences are very strong in decision Help teens identify the characteristics of a
making. healthy relationship and assess their own
Experimentation with relationships and sexual relationship quality.
behaviors is common. Peer counseling can be effective with this age
Concerned about relationships. group.
Sexual intercourse is increasingly common. Focusing on health promotion, prevention and
MIDDLE 44% of high school tenth graders and 56% of harm reduction is key.
ADOLESCENCE high school eleventh graders have had sexual Avoid making assumptions about sexual
intercourse.2 orientation and behaviors.
Females: 13-16 Increased abstract thinking ability. Help provide gay and lesbian youth with
years Full physical maturation is attained. positive role models and support systems.
Assess family response to youths sexual
Males: 15-17 years Dating is common.
orientation.
Sexual behaviors do not always match sexual
Be aware youth with disabilities, like their
orientation.
non-disabled peers, may be engaging in
Often aware of theoretical risk but do not see sexual behaviors and have questions around
self as susceptible. their sexual orientation
Reinforce parent-child communication about
sexual decision making and forming healthy
relationships.
Firmer and more cohesive sense of identity. More abstract reasoning allows for more
LATE Attainment of abstract thinking. traditional counseling approaches.
ADOLESCENCE Ability to establish mutually respectful/trusting Acknowledge and support healthy
relationships. relationships or the choice to not be in a
relationship.
Females: 16-21 Firmer sense of sexual identity.
years Concern for the future.
Males: 17-21 years Feelings of love and passion.
Increased capacity for tender and sensual love.
1
Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-US 2007. Morbidity and Mortality Weekly Report. 2008; 55(SS-4).
2
Ibid.

Adolescent Sexual Development cont.
The stages of adolescent development can be used as a guide to approaching counseling techniques in an age-
appropriate/developmentally appropriate manner. Keep in mind that these age delineations are generalized and that
actual development is affected by culture, abuse, and socialization.1
When considering the stages of development, be sure to.
Appreciate that the transition from childhood to adulthood may be a difficult and overwhelming.
Healthcare providers can make these transitions easier by providing guidance and information to teen
patients and their parents. For example, research has shown that menarche is less stressful when the
teen knows what to expect.
Assess social, biological, and cognitive stages of development. Keep in mind that physical development
does not always match cognitive and social development. Asking a question like, when do you think a
person is ready to have sex, can help identify where the teen is developmentally. When working with
youth with disabilities be age appropriate unless cognitive delays are evident. Even if a person needs
extra time to process information or has difficulty with language and expression, this does not mean
he/she doesnt understand at an age appropriate level.
Educate both adolescent girls and boys about the stages of development. Boys generally receive less
information than girls about developmental changes and puberty can be a confusing, uncomfortable
time for everyone.
Support your teen patients in developing healthy sexual relationships and healthy attitudes toward sex.
Ensuring that teens have a supportive adult in their life who can guide the teen while he/she builds
relationships is extremely important for their overall development into adulthood. The provider can
help the teen identify adults they can turn to.
Pay attention to how a teen feels about his/her development. Teens that develop earlier or later than
average are vulnerable to health and social problems. If you feel that a teen is developing faster/slower
than average, provide anticipatory guidance.
Realize that social pressures surrounding development are a reality for many teens. Girls who mature
earlier are at greater risk of becoming sexually active at a younger age than their female peers. Teen
boys who develop later can be bullied and are at higher risk for substance and/or tobacco abuse problems
than their peers who develop earlier.
1
Short M B, Rosenthal SL. Psychosocial Development and Puberty. Ann. N.Y. Acad. Sci. 2008; 1135:36-49.
Sources:
1) Neinstein, L. Adolescent Health Care: A Practical Guide, Philadelphia: Lippincott Williams and Wilkins, 2002.
2) Getting Organized: A Guide to Preventing Teen Pregnancy
3) Short MB, Rosenthal SL. Psychosocial Development and Puberty. Ann. N.Y. Acad. Sci. 2008; 1135:36-49.
4) Biro EM. Adolescent Sexuality: Puberty. Adol Med: State of the Art Reviews. 2007; 18:3.
5) Marcell AV, Monasterio EB. Providing Anticipatory Guidance and Counseling to the Adolescent Male. Adol Med: State of the Art Reviews. 2003; 14:3.
6) Facts for Families: Normal Adolescent Development. American Academy of Child and Adolescent Psychiatry. June 2001; 58.

Provider-Youth Communication
Providers play a critical role in encouraging healthy behaviors in adolescents. Encouraging teens to practice
making healthy decisions requires clear, nonjudgmental, confidential guidance or communication.
TIPS FOR TALKING TO TEENS

Remove distractions. Spend part of every visit with adolescent
patients alone. By asking teens in private if they want their parent
and/or partner involved in their care, they will be more likely to give
a comfortable answer. Also request that cell phones and pagers are
turned off - both yours and the teens.
Begin by discussing confidentiality and its limits. This helps

build trust and explains the basis for mandated reporting. These
requirements differ by state; if you are unclear on the limits to
confidentiality, contact your countys child protective services for
more information.
Negotiate the agenda. Make an effort to address the issue(s) that

brought your patient through the door, and explain what you need to cover during the visit. You can address
their concerns and yours while building trust along the way. Dont neglect to include a sexual history for a
youth with a disability.
Avoid jargon or complex medical terminology. Teens are often hesitant to ask for clarification. Simple,
straightforward language ensures effective communication of important information. Check for mutual
understanding by asking open-ended questions, and clarifying your patients slang in a nonjudgmental manner
(e.g., Tell me what you know about how a person can get HIV?; Ive never heard that term before, do you
mind explaining what ___ means? Unless it is natural for you, try to avoid using slang to relate.
Use inclusive language. Language that includes LGBTQ or gender variant youth builds trust and indicates
acceptance. Instead of do you have a boyfriend/girlfriend? try saying are you seeing anyone? or are
you in a relationship? The language we use when speaking of disabilities is important. For example, the
term disability is preferred over handicap and wheelchair user over wheelchair bound. Listen to the
language your patients use and, when in doubt, ask what is preferred.
Listen. This not only builds trust, but may give insight that affects the healthcare and advice you provide.
Respect an adolescents experience and autonomy. Many young people feel that adults and people in
positions of authority discount their ideas, opinions and experiences. Health care providers, together with
parents, can help patients make wise, healthy decisions.
RISK vs BLAME
Healthcare providers generally assess risk and protective factors when treating and providing guidance to teen
patients. There are many factors that put an individual at risk of negative health outcomes including living in
poverty, a violent neighborhood, a single parent home, etc. Many of these risks, however, are not by the choice
of the individual. When assessing risk and counseling on behavior change, avoid communicating blame to the
patient.

Provider-Youth Communication cont.
FRAMEWORKS FOR WORKING WITH YOUTH
Reinforcing Health Promoting Behavior (Harm Reduction)
While healthcare providers cannot control the decisions made by their patients, they do play an important role in encouraging
and reinforcing healthy decision-making. For example, when teens are engaging in risky sexual behaviors, teach them to
use a condom or other birth control methods correctly and consistently rather than solely focusing on trying to talk them out
of a sexual behavior that is deemed as risky. When teens are having oral sex, encourage them to use protection and abstain
from such an activity when they have a cold sore in their mouth, genital lesions or bleeding gums.
Motivational Interviewing
While many teens make healthy decisions, sometimes its clear that teens would benefit from changing their behavior.
Motivational Interviewing offers brief and effective methods for intervention and uses behavior change as a foundation for
working with youth. Motivational interviewing techniques have been effective for alcohol or substance use counseling.
There is increasing evidence of its usefulness for counseling around sexual health issues. For more information, see
Behavioral Health Module of the Adolescent Provider Toolkit.
The basic framework for Motivational Interviewing is as follows:
1. ASK PERMISSION to engage in the topic of discussion.
2. ASSESS READINESS for change and the youths belief in his/her ability to make a change.
1 2 3 4 5 6 7 8 9 10
On a scale of 0 to 10, how ready are you to get some help and/or work on this situation/ problem?
Straight question: Why did you say a 5?
Backward question: Why a 5 and not a 3?
Forward question: What would it take to move you from a 5 to a 7?
3. RESPOND TO PATIENTS READINESS

NOT READY FOR CHANGE (0-3): Educate, Advise and Encourage
UNSURE (4-6): Explore Ambivalence
READY FOR CHANGE (7-10): Strengthen Commitment and Facilitate Action
4. KEEP FRAMES IN MIND when counseling for behavior change

F: Provide FEEDBACK on risk/impairment (e.g. it sounds like your fear of getting pregnant is causing you a
lot of anxiety)
R: Emphasize personal RESPONSIBILITY for change (e.g. Id like to help you, but its also very important that
you take responsibility for changing things. What steps can you take to help yourself?)
A: Offer clear ADVICE to change (e.g. I believe the best thing for you would be to)
M: Give a MENU of options for behavior change and treatment (You could try)
E: Counsel with EMPATHY (I know that these things can be very difficult...)
S: Express your faith in the adolescents SELF-EFFICACY (I believe in you, and I know that you can do this,
when you decide the time is right)
Resource
Motivational Interviewing Resources for clinicians, researchers and trainers:
http://www.motivationalinterview.org

The Role of Providers in Parent-Child Communication
Providers play an important role in educating entire families on sexual health, sexual orientation and gender identity and facilitating
communication between adolescent patients and their parents. Healthy communication about sex between parents and children is
extremely important in ensuring that young people have the support and information they need to make healthy decisions about sex
and sexuality. Although it may seem difficult to encourage communication while still respecting the teens privacy, it is possible to
maintain confidentiality and at the same time promote parent-child communication.
The Benefits of Parent-Child Communication
Young people who feel connected to home and to their parent(s)/caregiver(s) delay initiation of sexual activity.1
Young people who have conversations with their parents about sex are also more likely to have conversations with their
partners about sex.2
Young people who regularly use contraception are more likely to report having had discussions about sex with their parents
than sexually active young people who are not using contraception.3
Young people whose parents talked to them about condoms are more likely to use a condom at first intercourse and more
consistently thereafter.4
Young people whose families and caregivers openly talk about their sexual orientation are at lower risk for health problems and
risky sexual behavior.5
TIPS FOR ENCOURAGING PARENT-CHILD COMMUNICATION
With Youth: With Parents:
Reiterate the importance of parent-child communication Reiterate the importance of parent-child communication
each time you talk with the teen. each time you talk with parents.
Ask why they do not want to involve a parent and try For parents of LGBT teens, tell them that family support
and get a sense of what they are afraid of. You cant decreases risk for HIV, STIs, suicide and promotes well-
force a teenager to talk to their parents, but you can being while family rejection increases these risks.5
probe further when a young person says they dont
Teach them medically accurate information, so that they
want to or cant talk to their parent about sensitive
can reinforce this at home.
issues.
Ask if they need help talking to their children or if there
Let LGBT teens know that families that reject their
are particular issues they find hard to discuss at home.
LGBT identity may be motivated by care and concern
for their teen and can become more supportive when Remind parents that teens are often afraid of disappointing
they learn how to provide support to their teen.5 their parents.
Ask if they need help talking to their parent about a Encourage taking advantage of teachable moments, such
particular issue and offer to meet with the youth and as when a young person asks a question or something
their parent together. is witnessed while watching TV together, for example,
where a bigger discussion and line of communication
If they feel uncomfortable talking to their parent,
can be opened up.
identify other caring adults in their immediate or
extended family that they can talk to. Help parents find ways to be involved while respecting a
young persons privacy and confidentiality.
Offer examples of ways that talking to parents/
caregivers can help to ensure that they get support. Encourage parents to initiate and sustain open dialogues
E.g., help getting to appointments or someone to talk about health and sexuality with their children. Help
to when confusing things happen with their peers. parents put themselves in the shoes of a young person,
to understand how difficult it is for their child to open up
Share examples of young people who were afraid to
about sexuality and health.
talk to their parent about a sensitive issue and how it
went better than they expected. Offer educational materials and resources about parent-
child communication. See pg. 66 and pg. 68.
Resources
Advocates for Youth - http://www.advocatesforyouth.org/
Guttmacher Institute - http://www.guttmacher.org/
1
Resnick, MD et al. Protecting Adolescents from Harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997; 278:823-32.
2
Whitaker, DJ et al. Teenage Partners Communication About Sexual Risk and Condom Use: The Importance of Parent-Teenager Discussions. Family Planning
Perspectives. 1999; 31(3): 117-21.
3
Hacker, KA et al. Listening to Youth: Teen Perspectives on Pregnancy Prevention. J of Adol Health. 2000; 26:279-88.
4
Miller, KS et al. Patterns of Condom Use Among Adolescents: The Impact of Mother-Adolescent Communication. Amer J of Public Health. 1998; 88: 1542-44.
5
Ryan C. Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children. San Francisco, CA: Marian Wright Edelman
Institute, San Francisco State University, 2009.
Minor Consent and Confidentiality
Adolescents list confidentiality concerns as the number one reason for delaying or forgoing medical care. During a
visit, teens are more likely to disclose sensitive information if consent and confidentiality is explained to them and they
have time alone with a provider. Providers should reclarify the laws and limits of confidentiality during each visit.
LEARN THE MINOR CONSENT AND CONFIDENTIALITY LAWS IN YOUR

STATE TIPS
Every state has different minor consent, confidentiality and mandated Be clear with minor patients
reporting laws. Almost all states allow teens to consent to STI testing and up front about confidentiality
treatment, as well as medical care for a minors child. Contrarily, most and its limits. Be as specific
states require some form of parental consent or notification before a minor as possible, so that they know
can obtain an abortion. what to expect and do not
Below is a link to an overview of minor consent laws for each state. This feel betrayed if something
chart is updated regularly, but should only be used for a quick reference. needs to be reported to a
More specific information about the laws in each state can be found in the parent or child protective
resources and links listed at the bottom of this section. services.
OVERVIEW OF MINOR CONSENT LAWS Explain that mandated
http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf reporting exists. Though
it can cause confusion at
Ensure CONFIDENTIAL Billing for Adolescent Sexual Health times, it is ultimately for
Services1 their protection.
Most private health insurance plans send home an explanation of benefits
(EOB) to the primary policy holder detailing services that have been Explain early on the
received by the minor. Confidentiality may be breached if a parent/ importance of confidentiality
caregiver receives an EOB detailing their childs reproductive or sexual between providers and
health services. minor patients to parents.
City, county, and/or state low- or no-cost family planning programs Rather than adversaries,
and Title X clinics do not send EOBs therefore disclosures regarding parents can be allies in the
confidential care are avoided. Many of these programs cover services provision of confidential
for to males too. healthcare for adolescents.2
Sometimes a referral to a Title X clinic is most appropriate if
confidentiality cant be ensured through insurance billing.
RESOURCES
Office of Population Affairs
Lists all Title X clinics by city, state, and zip code
http://www.opaclearinghouse.org/db_search.asp
National Center for Youth Law
Minor Consent and Confidentiality Information (AZ, CA, HI, IL, MI, NV, OH)
http://www.youthlaw.org/publications/minor_consent/
1
Billing for Confidential Adolescent Health Services. Society for Adolescent Medicine. http://www.adolescenthealth.org/clinicalcare.htm
2
Hutchinson, J. Stafford, E. Changing Parental Opinions About Teen Privacy Through Education. Pediatrics. 2005; 116(4): 966-971.

Healthy Relationships
The physiologic and cognitive impacts on romantic interest make adolescence an optimal
time for providers to begin conversations about trust, communication, and respect.
Regardless of whether a teen looks mature or displays a rebellious attitude towards
authority, teens need to hear positive messages reinforced by adults who demonstrate
an interest in their health and wellbeing. An assessment of relationships may also serve
as a vehicle for exploring topics such as sexual activity, condom and birth control use,
and intimate partner violence.
DISCUSSING HEALTHY RELATIONSHIPS WITH ADOLESCENTS:

Using the Healthy Relationships Wheel as a visual tool, ask the following four open-ended questions to begin a
conversation about Healthy Relationships:
accountability 1. Can you find any areas on the wheel that match
what your relationship with your girlfriend/
boyfriend/partner is like?
trust Safety
2. Which areas on the wheel are the most
important to you when you think of respect?
ReSPeCt Why?
3. How do you handle a disagreement in your

Support Honesty relationship? Which ideas on the wheel can
help you deal with conflict?
Cooperation
MESSAGES FOR HEALTHY RELATIONSHIPS

The two people are equal in the relationship.
Each shows some flexibility in role behavior.
Each avoids assuming an attitude of ownership toward the other.
They encourage each other to become all that they are capable of becoming.
Each avoids manipulation, exploiting and using the other.
RESOURCES
SIECUS: http://www.sexedlibrary.org/index.cfm?pageId=740
This site contains links to a variety of healthy relationship publications and data.
http://www.cdc.gov/Features/ChooseRespect/
The CDCs issue brief on healthy relationships.
1
Hedberg VA, Bracken AC, Stashwick CA. Long-term consequences of adolescent health behaviors: Implications for adolescent health services. Adol Med: State
of the Art Reviews. 1999; 10(1): 137-151.
2
Karney BR, Beckett MK et al. Relationships as Precursors for Healthy Adult Marriages: A Review of Theory, Research, and Programs. Rand Corporation, 2007.

Sexual Decision-Making
Healthcare providers play an important role in influencing the decisions that teens make surrounding sex. However, adolescents are
equally as likely to get information on sexual decision-making from television than from providers (60% and 62% respectively).1 By
encouraging communication between teens and their parents and educating youth about the responsibilities, benefits, and risks involved
with sexual activity, healthcare providers can facilitate healthy choices. Some of these choices may include initiating sexual activity at an
appropriate time or using condoms consistently.
THEMES INFLUENCING ADOLESCENT SEXUAL-

PROVIDER INTERVENTION STRATEGIES
DECISION MAKING2
1. Desire for Intimacy - Teens frequently report that desire 1. Encourage thinking about sexual intimacy in the context of
for intimacy/love and sexual attraction significantly healthy relationships and suggest using experience of pleasure
influence sexual decisions. (or lack there of), level of partner communication, and the
2. Perceived Relationship Safety Teens equate longer importance of safer sex as measures of sexual readiness.
term relationships with trust and safety. This often 2. Raise the issue of consistent condom use if there is risk for
results in the use of hormonal methods for pregnancy STIs. Discuss approaches to STI risk reduction (condom use,
prevention and decreased or inconsistent condom use. condom use with side partners, limiting number of partners,
3. Problem Solving and Cognitive Ability Higher etc.) as well as pregnancy risk reduction.
cognitive and reasoning ability may imply the ability to 3. Drugs and alcohol can impair decision-making skills.
be more thoughtful and mature with decision-making. Encourage teens to: discuss sexual decisions with their
Lower problem-solving skills and cognitive ability is partners before drinking; go to parties with a friend and
associated with earlier age of sexual debut. 50% of designate one to stay sober for the night; watch their drinks
females with learning disabilities will be mothers within to avoid date rape drugs.
3-5 years of leaving high school. 3
. Identify peer and parent attitudes toward sex. Affirm positive
. Family and Peer Influence The decision to initiate influences and dispel myths. For example, it is great that
sexual intercourse is often influenced by parents, peers you and your friends always use condoms. However, using
and sexual partners. For example, teens who talk to their two condoms at the same time does not increase your safety
parents about sex are more likely to have conversations and can cause condoms to break.
with their partners about sex.4 . If not using contraceptives, explore why. Identify barriers
. Concern for Pregnancy or STI Many teens to use and try to identify solutions. For example, if a teen is
underestimate their personal vulnerability for pregnancy worried about confidentiality, revisit confidentiality with the
and STIs. teen.
TIPS
Revisit the teens sexual history during each visit. Try and understand the social, cultural and cognitive circumstances of the
sexual activity. Use this as an opportunity to either educate or remind the teen of safer sexual behaviors and risk reduction
strategies.
Acknowledge and reaffirm positive behaviors and choices. Whenever possible, deliver some positive feedback to the teen.
Applaud teens for making an informed decision to remain abstinent or become sexually active.
Use harm reduction and motivational interviewing techniques to encourage behavior change. For more information on
motivational interviewing, refer to pg. 6.
Encourage parent child communication. For more information on parent-teen communication, refer to pg. 7.
Discuss the importance and meaning of healthy relationships. For more information on healthy relationships, refer to pg. 9.
Keep in mind that some teens may be having sex for reasons not outlined about (sex to get pregnant or test fertility, survival
sex). Use motivational interviewing and harm reduction techniques to explore these issues.
1
SexSmarts Survey. Kaiser Family Foundation, 2001.
2
Fantasia HC. Concept Analysis: Sexual Decision-Making in Adolescence. Nursing Forum. 2008; 43(2).
3
Washington Summit on Learning Disabilities. 1994.
42
Whitaker, DJ et al. Teenage Partners Communication About Sexual Risk and Condom Use: The Importance of Parent-Teenager Discussions. Family Planning
Perspectives. 1999; 31(3): 117-21.
Sources:
1) Weiss UJA. Let us talk about it: Safe adolescent sexual decision-making. J of the Amer Acad of Nurse Practitioners. 2007; 450-458.
2) Fantasia HC. Concept Analysis: Sexual Decision-Making in Adolescence. Nursing Forum. 2008; 43(2).
3) Planned Parenthood. Sex and Alcohol: Some Sobering Thoughts.
Adolescent Provider Toolkit C-10 Adolescent Health Working Group, 2010
Male Involvement
Young men are often not actively included in pregnancy and parenting discussions. They are sent the message early and
often by friends, parents, and healthcare providers that their role is fairly limited when it comes to pregnancy prevention
and parenting. Though there are realistic and legal limits to the role of young men in terms of decision-making about
birth control and pregnancy options, the provider plays an important role in helping young men (and young women)
understand the responsibilities and rights of fathers.
FAST FACTS
Teen boys and girls whose fathers are involved in their lives do not initiate sexual activity as early and are less
likely to get pregnant.
Children who live with their fathers are 5 times less likely to live in poverty than children who live separately
from their fathers.
Young people without involvement of their fathers are twice as likely to drop out of school, twice as likely
to abuse alcohol and other drugs, twice as likely to serve time in jail, and two to three times as likely to need
support for behavioral and emotional problems.
Source:
National Campaign to Prevent Teenage Pregnancy
MALE INVOLVEMENT IN PREGNANCY PLANNING

Healthcare providers can help young men understand their role in pregnancy prevention. Encourage male adolescents
to:
1. Take responsibility to prevent pregnancy. Help him learn how to use condoms correctly through a condom
demonstration in the office or other resources (video, handouts). Teach him what to do if the condom breaks.
Specifically, explain that he should tell his partner if the condom breaks and share with her information about EC, if
she is not on a hormonal birth control method. If he is 17 or older, he can buy EC over the counter.
2. Learn about hormonal birth control methods including Emergency Contraception (EC) using supportive handouts
or other resources. See pg. 26 for more information on EC and pg. 22 for information on hormonal birth control
options.
3. Talk about pregnancy and pregnancy prevention with his female partner(s). Provide the consistent message
that using both condoms and hormonal contraception is the best way to prevent pregnancy and getting STIs. If the
young man is interested in having children, ask him how he will determine when the time is right to become a father.
Encourage him to have these conversations with his partner and intentionally plan for pregnancy.
. Understand that he is in control regarding when and how his sperm is

released. Explain that he can choose not to have sex if he does not want to
and that there are alternatives to penetrative sex. Masturbation on ones own
or together with a partner are additional ways to avoid pregnancy and/or STI
risk. Advise him that once his sperm has left his body, he may not be able to
control the outcome if a condom was not used. Remind him that outcomes
from unprotected sex, e.g., pregnancy, may be associated with unexpected
legal and economic responsibilities.

Male Involvement cont.
. Estimate the costs of being a parent, especially for young men who are ambivalent about condom use and
fatherhood timing, using established worksheets or web-based resources. The following website, http://www.
babycenter.com/babyCostCalculator.htm, provides an estimate for first year baby costs.
ADDITIONAL STEPS PROVIDERS CAN TAKE INCLUDE:

1. Review condom use barriers e.g. why is it difficult to use, issues related to sensation, knowledge about various
condom shapes and sizes and that not one condom is made for all, variation by partner in use and suggestions how
to reintroduce condoms in relationships without impacting trust issues.
MALE INVOLVEMENT IN PARENTING

Assist young men who are fathers to understand their role in parenting. Providers should:
Ask all young men whether they have ever made someone pregnant and if they are a father.
Assess the degree to which they are involved in their child(ren)s life including emotional, physical, financial
support and barriers/facilitators to involvement.
Identify community resources such as parenting classes geared to young men, educational support, job training, etc.
that can positively assist young men in the parenting role.
Tips For Encouraging Male Involvement:
Approach young men as partners and assets rather than adversaries.

Conduct education with female clients to encourage them to involve their partners in reproductive
health and family planning, as well as pregnancy options.
Increase male-friendliness of clinics and medical offices. For example, display posters with images
of young men, use language that is inclusive of young men in pregnancy prevention educational
materials.
PATERNITY LAWS
For information on paternity and paternity laws, please see pg. 43.

For providers: screening, assessment & referrals
Taking a Client-Centered Sexual History
At a teens first visit or at ages 11-12, it is important to initiate discussion about sexuality. Teens want their healthcare
providers to ask these questions!
General Tips
Begin the sexual history AFTER you have established Use understandable language - avoid clinical terms.
rapport with the adolescent. (e.g. substitute having sex for intercourse)
Think about taking the sexual history in the context Ask adolescents for clarification when they say
of a HEADSSS assessment: Home, Education/ things you dont understand.
Employment, Activities, Drugs, Sexuality/ Suicide/ Use reflective listening. Paraphrase what the young
Depression/Self-Image, Safety. person has said and repeat it back to him/her.
Remember! Restate the parameters of confidentiality Do not make any assumptions, particularly about
before you take a sexual history. initiation of sexual activity, type of activity, gender
Use open ended questions that start with what, identity, and sexual orientation.
how, when, or tell me. Always acknowledge positive behaviors and assets
Be aware of judgmental questions (ex. you dont particularly establishing healthy relationships, proper
have unprotected sex, do you?) and behaviors (ex. use of contraceptives and safer sex methods, etc.
shaking your head as you ask questions). Educate teens about their options so they are in a
Frame some questions in the third person. (ex. Are position to make informed choices.
you noticing that your peers/friends are starting to Refer teens to other resources based on their
have sex?) individual needs.
Guidelines For Sexual History Taking

The following is an outline for taking a sexual health assessment based on the Five Ps Assessment (Partners, Prevention
of Pregnancy, Protection from STIs, Practices, and Past History of STIs). Taking a sexual history should always be
embedded in a general psycho-social assessment like Annotated HEADSSS.1 Consider these statements, questions,
and tips as a guide to assessing your teen patients.
INTRODUCTION
Im going to take a few minutes to ask you some sensitive questions. This information is important and will help me provide better
health care to you. Lets first discuss what information will be kept will be kept private and what information I might have to share
with other people (see. pg. 8 for information on minor consent and confidentiality).
STAGES OF DEVELOPMENT
Initial Questions Tips
Do you have any questions or concerns about During the onset of puberty, advice about hygiene can
your looks or appearance? become very important. Include discussions on bathing,
deodorant, and proper shaving techniques.
Do you have any questions or concerns about
your sexual development? Normalize the changes that happen during puberty. Assure
patients that they shouldnt feel ashamed about having wet
Do you have any questions, thoughts, or rules dreams and masturbation.
about masturbation? See pg. 3 for more information on the stages of adolescent
sexual development
1
Simmons M, Shalwitz J, Pollack S, Young A. Adolescent Health Care 101: The Basics. Adolescent Health Working Group. 2003. http://www.ahwg.net/assets/li-
brary/74_adolescenthealthcare101.pdf.
Sources:
1) Cavanaugh RM. Screening Adolescent Gynecology in the Pediatricians Office: Have a Listen, Take a Look. Pediatrics in Review. Sept 2007; 28(9).
2) Marcell AV, Bell DL. Making the most of the adolescent male health visit Part 1: History and anticipatory guidance. Contemp Pediatrics. 2006;23:6(38-46)

Taking a Client-Centered Sexual History cont.
SEXUAL ORIENTATION/SEXUAL ATTRACTION
Initial Questions Tips
Some of my teen patients are exploring new relationships. Do you Use gender neutral terms until the teen has
have a crush on anyone? Are you dating or seeing anyone?* established a preference for male/female sexual
Are you attracted to guys, girls, or both? partners.
Become familiar with resources for LGBT
Follow-Up Questions: youth in your area. Refer to community
How long have you been dating this person?* support programs for supportive counseling as
Are you having sex with anyone else?* needed.
Is your partner having sex with anyone else?* Provide anticipatory guidance to LGBT teens
Have you thought about having sex with him or her?* who report family rejection.
Who do you talk to about sex?* With younger teens, start by asking questions in
Follow-Up Questions for Lesbian/Gay/Bisexual Teens: the 3rd person, ie. Are any of your friends...?
Who have you told about your sexual orientation?* Sometimes teens, especially young teens, dont
use the word dating. Keep this in mind when
What are your familys reactions to your sexual orientation/identity?*
discussing their relationships.
Dont forget to address these issues with teens
with disabilities.
SEXUAL ACTIVITY
Initial Questions: Tips
Sexuality and relationships are things that many teens are dealing with; and Use the follow-up questions
different people are at different points in exploring these issues. Have these issues to determine if STI/pregnancy
come up for you? How?* prevention methods have been used
Follow-Up Questions: and which methods might be most
What do you consider having sex?* appropriate for him or her.
When do you think it is OK to have sex?* When sex is not enjoyable, assess
Have you ever had sex? (intercourse/outercourse)?* whether this is because they dont
If yes: want to be sexually active, have
Im going to ask you several questions about your experiences with sex, so that I a physical problem, or are having
can help you in making/keeping these experiences positive and healthy. problems with sexual function,
How old were you the first time you had sex? as the counseling messages are
Do you have sex with guys, girls or both? different.
Do you want to be having sex right now?
How often do you have sex? Protective Factors
How may people have you had sex with in the last 3 months? In your life? Sexual debut after 15 years of age.
For some people sex is generally a fun experience, for others it is not all that Has a trusted adult to talk to about
fun and may even hurt most of the time? What is usually your experience sexual issues.
with sex? For LGBT youth, have parents/
Has there ever been a time that you had sex but didnt want to? caregivers/families that support
Have you ever had sex when you were high on drugs or alcohol? their LGBT identity.2
If no:
When do you see yourself making the decision to have sex?*
Who do you talk to about sex?*
How do feel about having sex? Is it a good thing or bad thing for you?*
*Ask every adolescent patient regardless of sexual activity.

2

Taking a Client-Centered Sexual History cont.
SAFER SEX PRACTICES
Initial Questions:
Tell me some of what you know about STIs and HIV.* Tips
Use this opportunity to counsel teens about methods.
Follow-Up Questions: Congratulate those who are using contraception for
Have you or you partner ever been tested for STIs/HIV? had doing so, and encourage those who are not to initiate
an STI?* use.
Does your partner have other sexual partners that you know Remind them that condoms are most effective when
of? Do you? they are used correctly with every sexual encounter.
What questions do you have about STIs and HIV? Teens may be more likely to use protection with
casual rather than steady partners. Remind them to
Initial Questions:
use STI and pregnancy protection with all partners.
Are you doing anything to protect yourself against STIs/HIV
Screen for other risks, such as alcohol and substance
and pregnancy? What are you doing?
use and sexual abuse.
Follow-Up Questions: Refer teens to health education materials.
If the teen indicates that he/she has not been using protection,
Protective Factors:
ask:
Discussing contraception with partner before first sex
Have you used some sort of protection in the past?
Not currently sexually active or using reliable
What keeps you from using protection now?
methods to reduce pregnancy/STI/HIV risk
If the teen indicates that he/she sometimes uses protection, Using dual methods condoms in addition to a
ask: contraceptive method dedicated to the prevention of
With whom and when do you use protection? pregnancy (IUD, birth control pills, etc.).
What would help you to always use protection?
SEXUAL ASSAULT AND RELATIONSHIP VIOLENCE

Introduction:
Tips
Teens usually form healthy relationships. Unfortunately, some teens
Remind teens that you ask these questions because
are hurt by strangers, people they know or the people they date. I am
youre concerned about their safety. As a mandated
going to ask you a couple questions to make sure that you are safe.
child abuse reporter you must report abuse to your
Initial Questions: county child protective services or law enforcement
Have you ever been hurt in a sexual way or forced to have sex agencies.
when you didnt want to?3* Be aware that youth with disabilities (particularly
Have you ever traded sex for money, drugs, a place to stay or non-verbal and intellectually disabled youth) report
other things that you need? higher incidence of sexual abuse.4
Do you feel safe in your relationships? For more information on healthy relationships, see
pg. 9.
Follow-Up Questions: For more information on relationship violence, see
There are things people can do that may reduce their risk of pg. 30.
sexual assault. Do you know how to reduce your risk of sexual
For more information on sexual assault, see pg. 33.
assault?*
CLOSURE
At the end of the conversation, review what you learned and what you discussed.
For Example:
So, youve just told me that youre taking birth control pills to prevent pregnancy with your partner.
And that you two have talked about using condoms if either of you have side partners. Youre making
really good decisions and I encourage you to continue this smart behavior.
*Ask every adolescent patient regardless of sexual activity.
3
The American College of Obstetrics and Gynecologists suggests screening all patients at every visit for sexual assault. This following questions should be asked
of all patients whether or not they are currently sexually active.
4
Horner-Johnson W, Drum CE. Prevalence of maltreatment of people with intellectual disabilities: A review of recently published research. Mental Retardation
and Developmental Disabilities Research Reviews. 2006; 12: 5769.
Source:
STI Screening and Treatment
An Overview
SCREENING
A complete and accurate sexual history is needed to determine sexual risk based on practices and gender of partners. Because
STIs and HIV can remain asymptomatic, it is imperative that providers assess all sexually active teens for risky sexual and
drug-use behavior at health maintenance visits. For guidance on assessing risk and taking a sexual health history, please refer
to pg. 13.
Screening for Chlamydia and Gonorrhea (CT and GC)
Annual screening for CT in all sexually active females 25 Screening at the Discretion of the
years of age and younger and men who have sex with men is Provider
recommended by the Center for Disease Control and Prevention Currently, there are no screening guidelines
(CDC). for Chlamydia and gonorrhea (CT and GC)
Annual screening for GC in all sexually active females 25 years for men who only have sex with women
of age and younger is recommended by the U.S. Preventive (MSW) and women who only have sex with
Services Task Force, and supported by the CDC. Annual women (WSW).
screening of men who have sex with men is also recommended Providers may screen MSW selectively
by the CDC. Screening in very low prevalence populations for the following high-prevalence
(<1%) is generally not indicated. settings:
More frequent screening based on sexual risk. For adolescents, Correctional facilities
screening every 6 months in young women and every 3-6 STI clinics
months for men who have sex with men may be indicated. CT Adolescent-serving clinics
and GC screening can be performed at any visit type, regardless Individuals with multiple partners
of reason for visit.
Young WSW engaging in sexual
If the test is positive for either CT or GC, repeat screening 3-4
behaviors involving shared vaginal or
months after treatment.
anal penetrative items (digital, sex toys,
Screening for HIV etc.) are at risk of CT/GC and should
The CDC currently recommends an HIV test for all persons be screened at the discretion of the
aged 13-64 once, and periodic testing for those with on-going provider.
behavioral risks. See pg. 18 for more information on HIV testing For more information see the
and counseling recommendation. ARHP WSW fact sheet:
Screening for HPV www.arhp.org/factsheets
See pg. 20 for more information on HPV and HPV-related cancer Sources:
screening recommendations. 1) STI Epidemiology, Testing and Treatment Strategies.
Adolescent Reproductive Health Education Project,
Screening for other STIs PRCH, 2009.
2) Center for Disease Control. Sexually Transmitted
Any positive test for an STI is an indication to screen for all Diseases Treatment Guidelines 2006. Special Popula-
other STIs. For example, if a patient has trichomoniasis, he/she tions. http://www.cdc.gov/STD/treatment/2006/spe-
should be screened for CT, GC, syphilis and HIV. cialpops.htm. Accessed 1/29/10.
Men who have sex with men should be screened annually for
syphilis.
TREATMENT
For the most up-to-date treatment recommendations, refer to the CDCs guidelines:
http://www.cdc.gov/STD/treatment/default.htm
Chlamydia, gonorrhea, and syphilis are reportable STIs in every state. Other
reportable STIs vary by state and sometimes by county. See the CDCs Fastats from
A to Z for individual state data:
http://www.cdc.gov/nchs/FASTATS/map_page.htm
1
Youth Risk Behavior Survey, National Youth Behavior Survey: 2007.
2
Kaiser Family Foundation U.S. Teen Sexual Activity: Source footnote 7.
STI Screening and Treatment cont.
TIPS
Contact your local health department for prevalence rates and trends to help you tailor STI screening. STI trends
can vary significantly by state and county.
Keep in mind patient consent/confidentiality and let the patient know that you are screening him/her for STIs.
This is a great opportunity to educate teens about common STIs and safer sex methods.
Be aware that patient confidentiality may be compromised by mandated reporting of STIs. Even if the healthcare
provider does not file a report, laboratories will report any positive Chlamydia, gonorrhea or syphilis test. Become
familiar with local reporting practices around contacting patients and partners and advise patients accordingly.
Be aware of billing practices. Insurance claims sent home may breech confidentiality especially if tests for STIs
are listed.
Nucleic acid amplification tests (NAATs) are recommended for screening, and can be used on urine and self-
collected vaginal swab specimens, making a pelvic exam unnecessary.
NAATs can also be used on pharyngeal and rectal specimens.
EXPEDITED PARTNER THERAPY (EPT) AND PARTNER NOTIFICATION

Expedited partner therapy (EPT) is the empirical treatment of sexual partners of an individual who tested
positive for a sexually transmitted disease without provider evaluation. Under most circumstances, the patient
will deliver the medication to his/her sexual partners.
Partner notification is the act of informing ones sexual partner(s) that he/she has potentially been exposed to
an STI. There are three routes of partner notification: provider, patient, or contact referral.
EPT has been shown to be more effective than referring sexual partners for treatment of Chlamydia and
gonorrhea and has reduced rates of persistent or recurring infections in individuals including adolescents.
EPT for gonorrhea and Chlamydia is safe, effective and should be considered standard medical practice.
Providers need to consider the issues surrounding EPT use and partner notification in adolescents. Dispensing
EPT can breech patient confidentiality via insurance billing for medication and both EPT and partner notification
can result in mandated reporting if the partners birth date is required for prescriptions.
Resources:
CDCs full review of EPT: http://www.cdc.gov/std/EPT/. Guidance for use of EPT can be found on page 34.
InSpot.org: This website allows individuals who have tested positive for an STI to anonymously tell their
sexual partners through an ecard. The ecard then links the individual to resources for STI testing and treatment
in their area. Currently, InSpot is only available in 10 states and 9 metropolitan areas.
Sources:
1) Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Depart-
ment of Health and Human Services, 2006.
2) Golden MR, Whittington WLH, Handsfield HH, et al. Effect of Expedited Treatment of Sex Partners on Recurrent or Persistent Gonorrhea or Chla-
mydial Infection. N Engl J Med. 2005; 352(7): 676-685.
3) Hogben M, Burstein GR. Expediated Partner Therapy for Adolescents Diagnosed with Gonorrhea or Chlamydia: A Review and Commentary. Adol
Med Clinics. 2006; 17: 687-695.
4) CDC: Program Operations Guidelines for STD Prevention: Partner Services.
RESOURCES
Centers for Disease Control and Prevention
Sexually Transmitted Diseases Treatment Guidelines, 2006: http://www.cdc.gov/STD/treatment/2006/toc.htm
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings,
2006: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
US Preventive Services Task Force
Screening for Chlamydia Infection: http://www.ahrq.gov/clinic/uspstf/uspschlm.htm
Screening for Gonorrhea: http://www.ahrq.gov/clinic/uspstf/uspsgono.htm

HIV Testing and Counseling
Background
BASIS FOR UNIVERSAL HIV TESTING ANONYMOUS TESTING
Up to 30% of all new HIV infections occur in adolescents and young adults Anonymous testing is offered in some states at
13 to 25 years old.1 25% of individuals with HIV are unaware of their community based organizations or clinics. Clients
HIV diagnosis and account for approximately 54% of new infections.2 The may feel more at ease with anonymous testing.
Centers for Disease Control and Prevention recommend that all persons Refer to your state laws for more information.
13 years of age be tested for HIV at least once during their lifetime.3
More frequent testing is recommended based on risk for acquiring HIV. RAPID TEST
Rapid Tests are screening tests available at many
HIV TESTING METHODS
community or STI clinics and testing centers.
Usually, HIV infection is screened for by an EIA (enzyme immunoassay), Results are generally given within about 20
from a blood sample, to look for HIV antibodies. A positive or reactive minutes of processing and clients receive results
EIA requires a confirmatory test (such as the Western blot) to make the before they leave, enabling a built-in counseling
diagnosis of HIV. Depending on the lab, it may take up to 2 weeks to receive and referral session. All reactive/positive rapid test
results. There are limitations to this option. First, it may limit the ability to results must be confirmed by a blood test which
counsel patients. Second, because the patient must return in person, it may will require a follow-up visit. To find local testing
limit some people in receiving results. resources go to: www.hivtest.org.
HIV Counseling
The 2006 CDC guidelines recommend that HIV testing should be: 1) opt-out , with the opportunity to ask questions and the option to
decline testing; 2) performed without a separate written informed consent for HIV testing; and 3) prevention counseling should not be
required with HIV diagnostic testing or part of HIV screening programs in health-care settings. The CDC does recommend counseling
in nonclinical settings, such as at community-based organizations. There continues to be controversy around these areas and many state
laws are incongruous with the recommended guidelines.
The ACTS4 (Advise, Consent, Test, Support) program can be used to prepare an adolescent to have an HIV test, receive results and elicit
discussion around ways to prevent HIV quickly and efficiently. For more information about ACTS go to www.adolescentaids.org.
Adolescents may also be referred out to receive pre-test counseling using www.hivtest.org.
TO COUNSEL OR NOT TO COUNSEL?

While the CDC does not recommend counseling in health-care settings, there are times or situations that may warrant counseling.
REASONS FOR COUNSELING REASONS AGAINST COUNSELING
Adolescents prefer to receive STI/HIV information from
Routine or universal HIV testing (by itself without
their provider and studies have demonstrated that provider
counseling) was cost-effective even in low prevalent settings
recommendation remains one of the strongest predictors
(prevalence >0.1%).7,8
of testing.5,6
Normalizes HIV and makes it a part of regular STI
Identifies personal risk of HIV infections. screenings.
Reduces anxiety by preparing client for a positive Time constraints for primary care physicians
diagnosis. Counseling for HIV can be integrated into risk-reduction
Decreases cost of repeat testing and stress for clients with counseling for all clients when discussing other STIs and
no or low risk for HIV. drug use.
Opens discussion for additional testing and counseling Client has already been counseled before and does not need
more information.
Assesses social support.
1
Morris M, Handcock MS, Miller WC, et al. Prevalence of HIV infection among young adults in the United States: results from the Add Health study. Amer J Pub Health. 2006; 96(6):
1091-1097.
2
Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006; 20:1447-50.
3
MMWR Morb Mortal Wkly Rep 2006; 55:1-17.
4
Developed by the Adolescent AIDS Program at Montefiore Medical Center.
5
Goodman E, Tipton AC, Hecht L, Chesney MA. Perseverance pays off: health care providers impact on HIV testing decisions by adolescent females. Pediatrics. Dec 1994; 94(6 Pt
1):878-82.
6
Samet JH, Winter MR, Grant L, Hingson R. Factors associated with HIV testing among sexually active adolescents: a Massachusetts survey. Pediatrics. Sept 1997;100(3 Pt 1):371-7.
7
Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. Feb 2005; 352(6):570-85.
8
Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med. Feb 2005; 352(6):586-95.

HIV Testing and Counseling cont.
WHEN A CLIENT DECIDES TO TEST
Praise client for considering HIV testing
It is great that you are being proactive about your health and taking the initiative to test for HIV today.
Remove distractions (cell phones, partners, parents, etc.).
Discuss confidentiality laws specifically pertaining to testing, results, and parental/partner notification. Check for testing site
and state specific protocols and laws.
Assess risk (intravenous drug users, men who have sex with men, anal sex, inconsistent condom use, sex with a known
positive, history of STIs, sex in high prevalence community/network) and ways to reduce risk this can be included in
discussing ways to reduce risk for other STIs; Hepatitis and HIV.
What types of sex are you having? What are some ways that you could have safer sex in your relationships?
Discuss the window period. HIV antibodies take anywhere from 2 weeks to 6 months to be detected with the majority being
detected at 3 months. Depending on risk level and state of exposure, retesting may be indicated.
Prepare for a positive or negative diagnosis. Discuss the meaning (from patients perspective) of a positive or negative
test, what their life looks like moving forward, and who they can talk to when the appointment is over.
AFTER TESTING
In some states, giving HIV screening results over the phone is illegal, even in the case of a negative screening. Providers should
refer to state laws for more information.
If NEGATIVE, review the risk reduction plan, window period, and need to retest. Answer any questions the client may have.
If POSITIVE, refer to state-specific laws for follow-up. Many states require additional screening before diagnosis, and reporting
laws vary by state. Review the results, allowing additional time if the result is positive. You may want to have a social worker,
counselor, or nurse provider available to assess the client and assist with post-test counseling and link to HIV/AIDS services.
Discussion of partner notification and a risk reduction plan may need to be performed during a follow up visit. The first visit should
be used to repeat HIV testing, and give the client time to receive their result, to process and to assess the clients safety.
Giving HIV results can be stressful. Make sure to take a break to clear your mind and talk with another health care provider about
the experience.
Resources
http://www.adolesecentaids.org
HIV educational materials for youth.
http://www.thebody.com
Online resource for HIV/AIDS.
http://www.hivplus.com
Discusses issues related to HIV/AIDs.
http://www.poz.com
Popular magazine catered to HIV positive individuals.
http://www.mpowrplus.com
Popular magazine for HIV positive LGBT
community.
http://www.hivtest.org
CDC sponsored website that provides information on
HIV test centers by going to the website or texting a
zip code to KnowIt or 566948.
Image reproduced with permission by Pro-Choice Public Education Project.
Copyright 2005.

Human Papillomavirus (HPV) Related Cancers
Screening and Follow-Up
BACKGROUND
The new recommendations for cervical cancer screening are based on a growing understanding about the Human
Papillomavirus (HPV) and its causal relationship to 99% of cervical cancer.1 However, the actual incidence of
the virus causing neoplastic cervical lesions, particularly in young, healthy women, is extremely low. While
over 80% of sexually active people have the virus, most young women will clear the virus before pre-cancerous
cervical lesions occur.2 With this understanding the new recommendations are endorsed by the American Society
of Colposcopy and Cervical Pathology (ASCCP) and include new management guidelines specific to adolescent
women age 20 and younger with abnormal cervical cytology and histology.
1
American College of Obstetrics and Gynecology (ACOG), Committee on Adolescent Health Care. Evaluation and management of abnormal cervical
cytology and histology in the adolescent. ACOG. 2006; 107(4): 963-8.
2
Ibid
Screening
WHEN TO START SCREENING FOR CERVICAL CANCER1,2:

All women should begin Pap tests at the age of 21. All women, regardless of sexual orientation should undergo pap
test screening using current national guidelines.3 The data on cervical cancer incidence and the natural history of HPV
infection and of low- and high-grade cervical lesions suggest that a cervical lesion significant for neoplasm would take
5 to 10 years to develop after initial exposure to HPV.
Victims of sexual abuse: little to no data is available on victims of sexual abuse, however, no evidence suggests
that earlier screening would be beneficial, however abuse victims who have had vaginal intercourse, especially post
puberty, may be at increased risk of HPV infection and cervical lesions and should be referred for screening once
they are psychologically and physically ready (i.e., postpuberty) by a provider who has experience and sensitivity
working with abused adolescents.
Adolescents engaging in sexual activities excluding vaginal intercourse: the risk of HPV transmission to the
cervix is low for other types of sexual activity.
Concurrent STIs:
HIV infection: obtain two Pap tests in the first year after initial diagnosis of HIV infection and if results are
normal, annually thereafter.
All other STIs including genital warts: follow 2002 ACS recommendation
Anal HPV infection or anal cancer: precancerous lesions and HPV infection are common in HIV-positive
individuals and MSM. Because these populations may be at higher risk of developing anal cancer, some health care
providers recommend yearly anal pap tests. Currently, however, the CDC does not recommend anal pap tests due
to lack of evidence supporting their use in preventing anal cancer. HPV tests have not been approved for either anal
use or use in men and are likely not to be clinically helpful.4,5
1
2002 American Cancer Society Recommendations can be accessed from the CDCs website at http://www.cdc.gov/std/hpv/ScreeningTables.pdf.
2
ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Cervical Cytology Screening. Dec 2009; 109.
3
Center for Disease Control. Sexually Transmitted Diseases Treatment Guidelines 2006. Special Populations. http://www.cdc.gov/STD/treatment/2006/special-
pops.htm. Accessed 1/29/10.
4
http://www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm
5
Evans, D. Pap Smears for Anal Cancer? Poz Magazine. June 2008.

Human Papillomavirus (HPV) Related Cancers cont.
SCREENING FOR CERVICAL CANCER6:
Screening Intervals for normal cervical cytology and histology:
Conventional cervical cytology smears: After the initiation of cervical
cancer screening, continue with Pap tests every two years until the age
of 30.
Liquid-Based Cytology (Thin Prep): After the initiation of cervical
cancer screening, continue with Pap tests every two years until the age
of 30.
Intervals for screening women under 30 are more frequent due to the increased
likelihood of high-risk HPV acquisition.7
Image taken from FamilyDoctor.org: Pap Smear:
In women 20 or younger, HPV testing is not recommended due to the likelihood http://familydoctor.org/138.xml
of this population clearing the virus.
Follow-Up8
Recommendation for management of abnormal cervical cytology and histology in the event that the provider decides
to screen a young woman under 21
RECOMMENDATIONS FOR ADOLESCENTS

DIAGNOSIS
(AGED 20 OR YOUNGER)
Atypical Squamous Cells of Undetermined Significance Repeat Pap test in 12 months for up to two years;
(ASC-US) or Low-grade Squamous Intraepithelial Lesion then, if remains abnormal or HSIL at any visit refer to
(LSIL) colposcopy
Atypical Squamous Cells, Cannot Exclude High-grade
Colposcopy
Squamous Intraepithelial Lesion (ASC-H)
High-grade Squamous Intraepithelial Lesion (HSIL) Colposcopy
Colposcopy, endocervical assessment, possible
Atypical Glandular Cells* (AGC)
endometrial evaluation
Cancer Colposcopy, endocervical assessment
Cervical Intraepithelial Lesion - mild cervical dysplasia Repeat Pap at 12 month intervals, if HSIL or greater, refer
(CIN I) back to Colposcopy.
Close follow-up at 4-6 month intervals, with cytology and
Cervical Intraepithelial Lesion - moderate cervical
colposcopy; treatment is recommended if CIN II remains
dysplasia (CIN II)
at two years
Cervical Intraepithelial Lesion - severe cervical dysplasia
Ablative or excision therapy
(CIN III)
*Associated with malignant or pre-malignant lesions in up to 40% of women (age over 35 confers greater risk)
For further recommendations regarding management of colposcopy results and/or the management of pregnant
adolescents with abnormal cervical cytology and histology refer to CDC website at http://www.cdc.gov/std/hpv/default.
htm#resources and refer to the Clinicians Resources section.
6
ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists. Cervical Cytology Screening. Dec 2009; 109.
7
Center for Disease Control and Prevention (CDC) (2007). Human papillomavirus (HPV): Prevalence of high-risk and low-risk types among females 14 to 59
years of age reported from a national survey, 20032004. Accessed from http://www.cdc.gov/std/stats07/figures/43.htm on May 12, 2009.
8
ASCCP Recommendations for the Management of Women with Abnormal Cervical Cancer Screening Tests which can be accessed at http://www.asccp.org/con-
sensus.shtml.

Things to Consider When Prescribing Birth Control
WHEN COUNSELING ABOUT CONTRACEPTION OPTIONS:
First ascertain what methods the teen knows about Have the teen repeat back and demonstrate the cor-
and is interested in. rect use of the method.
Briefly describe all options. Guide them in their Schedule a future visit to ensure that the method is
decision based on their comfort level, needs and working right for him/her.
behaviors. Always re-emphasize the importance of condom
Describe the chosen method in greater detail to en- use to prevent STIs in addition to choosing an alter-
sure that the teen knows how to use it effectively. native method of birth control.
Suggest ways to include the teens partner in discus-
sions about contraception.
IS THE INTRAUTERINE DEVICE (IUD) AN OPTION FOR YOUTH?

Health care providers trained since the 1970s have generally considered IUDs to be
contraindicated in adolescents. The Dalkon Shield, a popular IUD with young women in
the 1960s and early 70s was associated with severe pelvic infections, ectopic pregnancies
and infertility and effectively created an association between any IUD and poor outcomes
in adolescents. Recent data shows that the association between IUDs and pelvic infections
is primarily related to infections in the first few weeks after insertion and likely reflects
insertion in women already infected with Gonorrhea or Chlamydia.
Contraindications for IUD initiation: World Health Organization medical eligibility criteria1
Current purulent cervicitis, chlamydia or gonorrhea infections
History of an STI in the past three months
Very high individual likelihood of chlamydial and gonorrhea exposure
More than 1 sexual partner in past 3 months
Partner who has multiple sexual partners
Partner who has been diagnosed with an STI or has STI symptoms in past 3 months
Some, but not all, adolescents have these risks; therefore this method should not be categorically
considered inappropriate for all adolescents. Even in the presence of an STI, currently available
IUCs are not independently associated with pelvic infections or tubal infertility.2
The following are NOT IUD contraindications:

Remote history of STI if no longer at increased risk
Nulliparity
History of PID
History of ectopic pregnancy
Although the expulsion rate of recently inserted IUCs is slightly higher in women who have
never borne a child, nulliparity is not a contraindication.3 IUDs are highly effective, long acting
(5 years for the levonorgestrel intrauterine system, Mirena; 10 years for the intrauterine copper
contraceptive, Paragard), invisible, reversible and easy to maintain all attractive characteristics
for adolescents. In particular, adolescent mothers, a group at very high risk for repeat pregnancy,
may benefit from this contraceptive option.4
1
World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva: WHO; 2004 (Update, 2008). Available at http://www.who.int/re-
productive-health/publications/mec. Accessed 7/23/08.
2
Toma A, Jamieson MA. Revisiting the intrauterine contraceptive device in adolescents. J Ped Adol Gynecol. Aug 2006;19(4):291-296.
3
World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva: WHO; 2004. Available at http://www.who.int/reproductive-health/
publications/mec. Accessed 7/23/08.
4
Toma A, Jamieson MA. Revisiting the intrauterine contraceptive device in adolescents. J Ped Adol Gynecol. Aug 2006;19(4):291-296.

Things to Consider When Prescribing Birth Control cont.
FDA BLACK BOX WARNINGS AND OTHER SAFETY INFORMATION
Depo-Provera Depot medroxyprogesterone acetate (DMPA)
In 2004, the FDA placed a black box warning label on the Depo-Provera Contraceptive Injection concerning the
risk of bone density loss after prolonged use. The warning states that Depo-Provera CI should be used as a long
term birth control only if other birth control methods are inadequate.1
The Society for Adolescent Medicine recommends that providers continue prescribing DMPA to adolescent girls
along with providing an explanation of both the benefits and risks.2 Evidence has shown increased bone mass
accrual after discontinuing use of DMPA and therefore, the benefits prescribing an effective contraception can
outweigh the risk of bone density loss.
For teens receiving DMPA, the Society for Adolescent Medicine recommends daily calcium supplements,
vitamin D and daily exercise. While calcium and vitamin D have not been proven to offset bone density loss,
these supplements are known to have broad health benefits for this population. Estrogen supplementation may be
considered in girls with osteopenia.3
1
U.S. Food and Drug Administration. Black box warning added concerning long-term use of Depo-Provera Contraceptive Injection. Available from: http://
www.fda.gov/bbs/topics/ANSWERS/2004/ANS01325.html. Accessed 8/19/08.
2
Tolaymat LL, Kaunitz AM. Long-acting contraceptives in adolescents. Curr Opin Obstet Gynecol. 2007; 19:453-460.
3
Society for Adolescent Medicine. Depot Medroxyprogesteron Acetate and Bone Mineral Density in Adolescents The Black Box Warning: A Position Paper
of the Society for Adolescent Medicine. J of Adol Health. 2006; 39:296-301.
Ortho Evra and the birth control patch

In 2006, the FDA amended the label for Ortho Evra to warn women of potential increased risk for venous
thromboembolism (VTE) when using the patch. The warning was based on the results of two epidemiological
studies with conflicting data on potential for increased risk for VTE.
Given the lack of substantive safety data for the use of the birth control patch, the World Health Organization
Medical Eligibility Criteria for Contraceptive Use (WHOMEC) suggests using the same guidelines for combination
oral contraceptives when prescribing the birth control patch.
Sources:
1) Burkman, RT. Clinical Opinion: Transdermal hormonal contraception: benefits and risks. Amer J of Obstetrics and Gynecology. August 2007; 134:e1-6.
2) Elliott TC, Montoya CC. How does VTE risk for the patch and vaginal ring compare with oral contraceptives? The Jof Family Practice. October 2008; 57: 10.
QUICK START ALGORITHM

Initiation and continued use of hormonal contraception is more likely if a teen can initiate the method right away,
rather than waiting for her next menses.1 Providers can feel reassured regarding the safety of this approach, as studies
have shown the inadvertent exposure to the hormones used in combined oral contraceptives early in pregnancy has no
detrimental effect on the developing fetus.2 This approach, known as Quick Start has been evaluated for a variety of
hormonal methods, including OCPs, DMPA, the transdermal contraceptive patch and the contraceptive ring.3,4,5,6
The principles of quick start regimens are to:
1. Rule out a detectable pregnancy prior to method initiation
2. Provide Emergency Contraception if indicated
3. Initiate the method immediately
4. Counsel the youth to use condoms for 1 week and obtain a follow-up pregnancy test in 2 weeks if the method
was initiated after day 6 of the menstrual cycle.
This approach is easily followed using the very clearly outlined Quick Start Algorithm on the next two pages.
1
Zurawin RK, Ayensu-Coker L. Innovations in contraception: a review. Clin Obstet Gynecol. June 2007;50(2):425-439.
2
M.B. Bracken , Oral contraception and congenital malformations in offspring: a review and meta-analysis of prospective studies. Obstet Gynecol. 1990; 76:552557.
3
Westhoff C, Heartwell S, Edwards S, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet
Gynecol. June 2007; 109(6):1270-1276.
4
Nelson AL, Katz T. Initiation and continuation rates seen in 2-year experience with Same Day injections of DMPA. Contraception. Feb 2007; 75(2):84-87.
5
Murthy AS, Creinin MD, Harwood B, Schreiber CA. Same-day initiation of the transdermal hormonal delivery system (contraceptive patch) versus traditional initiation
methods. Contraception. Nov 2005; 72(5):333-336.
6
Schafer JE, Osborne LM, Davis AR, Westhoff C. Acceptability and satisfaction using Quick Start with the contraceptive vaginal ring versus an oral contraceptive. Contra-
ception. May 2006; 73(5):488-492.

Quick Start Algorithm

Woman requests a new birth control method
1. Pill, Patch, Ring, Injection
First day of last menstrual period (LMP) is:
5 days ago >5 days ago
Urine pregnancy test: negative**

Start method
today, use back up
method 1st week Unprotected sex since LMP:
Both <and>
5 days ago >5 days ago 5 days ago None
Advise that Start pill/

Offer negative Offer
hormonal EC hormonal EC patch/ring/
pregnancy test injection today,
today* is not conclusive today*
use back-up
but hormones will method 1st
not harm fetus week
Patient wants to start new method now?
YES NO
Give prescription for chosen method;

Start pill/patch/ring/injection, use
back up method 1st week advise patient to use barrier method
until next menses
TIMING: Start pill/patch/ring on 1st day of

Start new method TODAY if not taking menses; return for injection within 5
EC; start new method TOMORROW if days of menses
taking EC today
Two weeks later, urine pregnancy test

is negative;** continue pill/patch/
ring/injection
* Because hormonal EC is not 100% effective, check urine pregnancy test 2 weeks after EC use.
**If pregnancy test is positive, provide options counseling.
Source:
2005 Pocket guide to Managing Contraception by Hatcher RA, Zieman M et al, page 135. Reproduced with permission from RHEDI/The Center for Repro-
ductive Health Education in Family Medicine.

Quick Start Algorithm

2. PROGESTIN IUD or Implant

Insert IUD/implant
today Unprotected sex since LMP?
YES NO
Offer pill/patch/ring as bridge to IUD/implant

Insert IUD/
implant today
Patient declines pill/patch/ring,
Patient accepts pill/patch/ring uses barrier instead
Two weeks later, urine pregnancy Insert IUD/implant within 5 days of

test is negative** next menses
Insert IUD/implant today
3. Copper IUD
Insert IUD/implant First episode of unprotected sex since last LMP:

today
5 days ago >5 days ago None
Insert IUD within Insert IUD today

Insert IUD today 5 days of next
menses*
* Pill/patch/ring may be started as a bridge to copper IUD.
**If pregnancy test is positive, provide options counseling.
Source:
2005 Pocket guide to Managing Contraception by Hatcher RA, Zieman M et al, page 135. Reproduced with permission from RHEDI/The Center for Repro-
ductive Health Education in Family Medicine.

Emergency Contraception
Fast Facts
EC is safe and effective birth control that can be used EC pills may cause side effects such as nausea, vomiting,
after unprotected intercourse (including sexual assault) or and breast tenderness. If a patient vomits within one hour
underprotected sexual intercourse. of taking EC, the dose should be repeated. Levonorgestral
EC comes in the form of pills which are most effective only products generally cause less side effects than the
when taken immediately, but reduce the risk of pregnancy combined estrogen-progestin EC.
when taken within 120 hours. EC also comes in the form There are no state or federal laws that require parental
of a copper IUD, which must be inserted within 5 days consent or parental notification for the provision of
of unprotected intercourse.* (Please refer to pg. 22 for EC. Some healthcare providers, however, have their own
recommendations for use of IUDs with adolescents). parental notification policies for prescribing EC to patients
EC pills work by delaying or inhibiting ovulation, under 18. Patients should ask their healthcare provider
inhibiting fertilization, or preventing implantation of a about these policies before receiving care.
fertilized egg (although this mechanism has never been Think about prescribing EC in advance with refills
clinically demonstrated). It will not interrupt a pregnancy to all of your sexually active teen patients. Educate them
that has already begun, like RU-486, the abortion pill. about its use, so they are prepared for an emergency.
This is an important point for many teens!
EC pills significantly reduce the risk of pregnancy
after one instance of unprotected intercourse and are more
effective the sooner they are taken.
*Currently, the efficacy of progesterone receptor modulators as an alternate form of EC is being studied.
TYPES OF EMERGENCY CONTRACEPTIVE PILLS

TYPE OF PILL PRODUCTS DOSAGE
1 pill each dose1 (Repeat in
Progestin-only (Levonorgestral) Next Choice (Generic EC)
12 hours)
DEDICATED
Progestin-only (Levonorgestral) Plan B One Step 1 pill
PRODUCTS
The dedicated Levonorgestral products are generally the most appropriate form of EC for teens. The
side effects are usually minimal and dosing instructions are simpler than with other EC methods.
Progestin-estrogen combined (in 28 day Various combined birth Dosage depends on type
packs, only the first 21 pills can be used) control pills2 of pill2
ORAL
CONTRACEPTIVES Only 16% of self-identified sexually active students nationwide reported use of oral contraceptive
(OC) pills by themselves or their partner, therefore, use of OCs as EC is less utilized in teens.3 For
USED AS EC
teens that need EC while using OCs, this may indicate that they are on the wrong contraceptive
method. This is a great opportunity to discuss alternate contraceptive options.
1
Although it conflicts with instructions on the box, current practice also includes administering 2 pills at one time up to 5 days after unprotected sex, but sooner is
always better: Allen RH, Goldberg AB. Emergency Contraception: A Clinical Review. Clin Obstet and Gynecol. Dec 2007; 50(4).
2
Refer to NOT-2-LATE.com: http://ec.princeton.edu/questions/dose.html for specific dosages for common birth control pills.
Access to Plan B
Over the counter: In 2009, the FDA approved Plan B for over the counter use by men AND women 17 years and older. In the
future, the generic product may be available for over the counter use.
Prescribing EC pills: Women under 17 can access Plan B with a prescription from a healthcare provider. Women under 18 can
access the generic product with a prescription. Counsel young men about EC even though they cannot receive a prescription.
Pharmacy Access: In nine states (AK, CA, HI, MA, ME, NH, NM, VM, WA) women of any age can obtain Plan B directly
from a pharmacist. Patients should be advised to call their local pharmacy to see if they participate in the Pharmacy Access
Program. Access without a prescription can be limited due to pharmacists willingness or unwillingness to dispense Plan B.
Pharmacy Access may increase the cost of Plan B because an extra counseling fee is added onto the cost.
Cost: The average cost of Plan B without insurance is $31 per package*. This cost may vary and patients should contact their
insurance companies to find out whether or not it is covered. Many states also have family planning funding programs that
subsidize the cost of Plan B and other contraceptives. However, the generic product may be the least expensive option.
* Allen RH, Goldberg AB. Emergency Contraception: A Clinical Review. Clin Obstet and Gynecol. Dec 2007; 50(4).

Emergency Contraception cont.
When assessing a patient for emergency contraception, ask:
Tips and Follow-Up Questions
When was the last time you had unprotected intercourse? Was in it the last
3-5 days? Have you been screened recently for
Chlamydia and gonorrhea? If not,
Why do you think you need EC? offer screening. See pg. 16 for STI
If the teens last unprotected intercourse happened in the screening guidelines.
last 3-5 days, prescribe EC pills.
Was this a sexual assault? If so, see
If the response to the first question indicates increased pg. 33 for more information on sexual
likelihood of pregnancy, or you question the accuracy of the assault and abuse.
history, you can still prescribe the pills, but there is a greater
chance the patient might be pregnant. (Run a preg test to assure How often are you having
appropriate care.) unprotected sex? If unprotected sex is
frequent, counsel on different methods
If you prescribe EC pills, and see pg. 39 for more information on
YOUR PATIENT SHOULD BE AWARE THAT: BC.
She might still get pregnant.
She might experience side effects such as nausea, vomiting, and breast tenderness.
If she vomits within an hour of taking EC, she should repeat the dose. Side effects are less common with Plan B or
generic.
EC will not protect against pregnancy related to unprotected intercourse occurring after she takes the pills.
Her next menstrual period might not start at the expected time or be of the usual flow or duration.
ECPs do not protect against STIs.
ECP should not be used as a regular form of birth control because they do not prevent pregnancy as effectively as other
form s of contraception.
CONSIDER THE FOLLOWING:
Patients should be counseled further about consistent and reliable birth control use.
Patients should be counseled further about the risks of STIs involved with unprotected sex.
Patients should return for a follow-up appointment to confirm they did not become pregnant, if they do not get their period
within two weeks of the expected date. Use this as an opportunity to reinforce regular contraceptive practices.
If you prescribe the copper IUD

CONSIDER THE FOLLOWING:
Ascertain if the patient desires long term contraception (method is effective up to 10 years)
Rule out Chlamydia or gonorrhea infection.
Rule out other contraindications for use of the IUD.
If a patient does not have health insurance, the cost of the IUD may be prohibitive
unless the teen is in a locale with a public family planning program.
Refer to pg. 25 for the quick start algorithm for the copper IUD.
Resources:
http://www.not2late.com
http://www.go2planb.com
http://www.ec-help.org
1
Youth Risk Behavior Surveillance, United States, 2007.
2
Allen RH, Goldberg AB. Emergency Contraception: A Clinical Review. Clin Obstet and Gynecol. Dec 2007; 50(4).
Sources:
1) Allen RH, Goldberg AB. Emergency Contraception: A Clinical Review. Clin Obstet and Gynecol. Dec 2007; 50(4).
2) What You Need to Know: The Facts about Emergency Contraception. Association of Reproductive Health Professionals (ARHP). Updated January 2008.
3) Emergency Contraception: A Practitioners Guide. Physicians for Reproductive Choice (PRCH), 2008.
4) What Consumers Need to Know about Obtaining Plan B Over-the-Counter in Pharmacies. Pharmacy Access Partnership. Rev Aug 2009.

Pregnancy Test Counseling
BEFORE DELIVERING THE TEST RESULTS:
What brings you here today?
How would you feel if you were pregnant?
If last incidence of unprotected or under-protected sex occurred
I know youre sexually active right now. Is this
in the past 3-5 days, assess appropriateness of emergency
something you are enjoying? Do you feel comfortable
contraception.
with your partner?
What are you hoping the test result will be?
Are you doing anything to prevent getting pregnant or getting STIs? Are you happy with this method?
IF THE TEST IS NEGATIVE:

Explore personal beliefs and attitudes about TIPS
pregnancy: Remind her that just because she did not become pregnant this
How would you have felt if the test were positive? time, it does not mean she will never get pregnant. Identify
What do you think is the best age to get pregnant? successful female role models and goals and plans for the near
What are your goals and ideas for the next year? and distant future.
For the future? Use these responses to assess contraceptive methods that
Screen for risks of unprotected sex including would work best for the teen given her readiness, motivation
and method of choice. It may help to role-play scenarios to deal
pregnancy, STIs and forced sex:
with this issue. For example, if she begins oral contraceptives,
Conduct a HEADSSS1 assessment. act out how she might handle her mother finding her pills. Role-
Discuss relationships and support of family/ play discussing contraceptives with her partner/boyfriend.
friends/partners: Based on her answers, counsel on consistent and effective
Who knows you came here today? Who knows that contraceptive use, and/or the realities of pregnancy (financial,
you think you might be pregnant? physical, personal, emotional). Write her an advance
How would/do your parents feel about your sexual prescription for emergency contraception and discuss its
activity? effects and uses (see pg. 26 for more details on EC).
How does your partner/boyfriend feel about Contact your patient by phone to see how things are going
pregnancy, birth control and safer sex? if she does not return for a follow-up. 56% of teens with a
Do you have friends or family members who are negative pregnancy test become pregnant in the next 18
pregnant or have babies? months, so follow up care is vital.2
IF THE TEST IS POSITIVE:

Explore knowledge and beliefs about parenting, abortion, and adoption:
Did you plan to get pregnant?
How do you feel about being pregnant?
What options have you considered (adoption, abortion, etc.)?
What does your family, religion or culture think about pregnancy? abortion?
What is your experience with pregnancy and parenting?
Have any of your friends or relatives been pregnant recently? What did they decide to do about their pregnancies?
Assess social and family history:
Who do you confide in?
Who knows that you might be pregnant?
How are you doing in school?
What do you want to do in 1 year? 5 years?
Do you have insurance? Can you use it without worries of confidentiality?
1
For a full HEADSSS Assessment refer to the Basics of Adolescent Health Toolkit Module: Adolescent 101.
2
Vyas S. Adolescent Pregnancy: A Pediatric Residents Perspective. Ped Annals. 2002; 31(9).

Pregnancy Test Counseling cont.
Conduct medical history:
Do you have any medical problems or are you taking any medications?
What methods have you used to prevent pregnancy or STIs?
Have you had a pregnancy test before?
Have you been pregnant before? Do you have children? What did you do about your past pregnancies?
Have you had any STIs before?
Have you had any bleeding/spotting or abdominal pain since your last period?
Discuss family/friends/partner influences:
What adults in your life will be supportive?
Does anyone know you came for a pregnancy test today?
What is your relationship with the man you are pregnant by? Are you still seeing him? Do you think he will be supportive?
How would/do your parents feel about your sexual activity?
How does your partner/boyfriend feel about pregnancy, birth control and safer sex?
How do you think your family and friends will react?
Do you have friends or family members who are pregnant or have babies?
Discuss concrete options including health risks and costs of the options.
Who will you talk to about this?
Do you need any help in talking about your pregnancy plans with your boyfriend, parent(s), or other significant adults?
Do you have someone to accompany you to your appointments? (prenatal or abortion)
Do you know what your options are? What do you think you would like to do?
TALKING POINTS
Parenting Abortion Adoption
Emphasize the importance of prenatal care Closed adoption
Medical
Medicaid enrollment/health coverage options Birth mother and father remain anonymous to
Surgical
Impact on finishing school adoptive parents
Access to abortion
Finances Open Adoption
Timing
Relationship with father of the baby Birth mother chooses the adoptive parents and
Cost
Social support they may stay in touch
Schedule follow up appointment(s), as needed, for physical exam, additional counseling and referrals.
Medical v. Surgical Abortion: Which is more appropriate for teens?

MEDICAL ABORTION SURGICAL ABORTION
PROs CONs PROs CONs
Can cause
Requires a follow-up appointment
Doesnt require Usually requires only one appointment minimal cramping
Causes heavy bleeding for several
surgery Immediate results during or after the
hours and bleeding may continue for
Can be more Performed at weeks 6-23 of pregnancy procedure
~2 weeks
private Procedure does not take a long time Light bleeding
Bleeding timing and duration is
Can feel more Minimal bleeding after procedure may last up to two
unpredictable
natural Is more effective than medical abortion weeks after the
Limited to weeks 4-9 of pregnancy
procedure
Resources: Safe Haven Laws

http://guttmacher.org/statecenter/spibs/spib_PIMA.pdf Safely Surrendered Baby Law allows parents to confidentially
State policies on parental involvement in the abortion of minors. give up their baby, 72 hours or younger. As long as the baby
has not been abused or neglected, parents may give up their
http://guttmacher.org/statecenter/spibs/spib_MAPC.pdf newborn without fear of arrest or prosecution.
State policies on minors access to prenatal care. http://www.nationalsafehavenalliance.org
Sources:
1) Utilizing Decision: Pregnancy Options Counseling. Physicians for Reproductive Choice and Health.
2) Thinking About Adoption. Planned Parenthood. http://www.plannedparenthood.org/health-topics/adoption-4261.htm
3) Medical vs. Surgical Abortion. UCSF Medical Center. Updated 05/2007. http://www.ucsfhealth.org/adult/edu/abortion.html
Adolescent Relationship Violence (ARV)
Adolescents should be routinely screened for relationship violence; and, providers should help youth/parents understand
and develop healthy relationships. By learning about local resources and how to support victims, healthcare providers
can ensure that their patients are safe and/or have a strategy to deal with partner violence or abuse.
FAST FACTS
Adolescent relationship violence is defined as the intentional violent or controlling behavior by a person who
is currently or was previously in an intimate relationship with the victim. Sexual abuse or assault can be
associated with intimate partner violence but is not always an issue.
1 in 3 teens experience some kind of abuse in their romantic relationships, including verbal and emotional
abuse.1
1 in 5 female students report physical and/or sexual abuse by dating partner.2
Teens in same sex relationships are just as likely to experience relationship violence. Studies show that 20%-
50% of same sex relationships may be abusive.3
A recent study found significant levels of abusive behavior in tween (ages 11-14) dating relationships, and
teens report that abusive behavior increases dramatically in the later teen years.4
Youth perpetrators are equally likely to be female or male: girls more likely to be victims of physical abuse and
boys victims of psychological abuse and mutual aggression is common.5
RISK FACTORS FOR VICTIMS RISK FACTORS FOR PERPETRATORS

Poor self-esteem
Younger age with older partner(s) Aggressive behavior, jealous, blaming
History of prior ARV Poor interpersonal skills/problem solving
Substance abuse Substance abuse
Initiation of sex before 15 years old Personal history of physical abuse
Multiple partners Growing up in a household where DV is
Pregnancy occurring
The Cycle of Violence

Adolescent relationship violence generally follows a
progression that is referred to as the cycle of violence. The
cycle usually starts with the tension phase followed by a
violent or abusive episode followed by the honeymoon or
apology phase. With each repetition of the cycle, the acts of
violence/abuse tend to escalate and transition time between
episodes decreases. It is important to explain this cycle when
you are counseling a youth who may be involved in ARV.
Image taken from http://extension.missouri.edu/publications/Dis-

playPub.aspx?P=GH6608
1
Halpern CT, et al. Partner Violence Among Adolescents in Opposite-Sex Romantic Relationships: Findings From the National Longitudinal Study of Adolescent
Health.Amer J of Pub Health. 2001; 91:1680.
2
Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating Violence Against Adolescent Girls and Associated Substance Use, Unhealthy Weight Control, Sexual Risk
Behavior, Pregnancy, and Suicidality. J of the Amer Med Assoc. 2001; 286(5).
3
National Coalition of Anti-Violence Programs. Lesbian, Gay, Bisexual and Transgender Domestic Violence in 2001. New York, NY; 2002.
4
Liz Claiborne Inc. study on teen dating abuse conducted by Teenage Research Unlimited, Feb 2008.
5
Mulford C, Giordano, PC. Teen Dating Violence: A Closer Look at Adolescent Romantic Relationships. NIJ Journal. Oct 2008; 261.

Adlescent Relationship Violence (ARV) cont.
Screening Tips and Guidelines

It is important to look for signs and symptoms of ARV. Many of these signs and symptoms may surface during a
HEADSSS assessment.1
SIGNS OF POSSIBLE ARV
Clinical Complaints Behavioral Partner Behaviors
Chronic complaints of abdominal Hostile and secretive Is possessive, jealous of others,
pain, headaches, vaginitis, Moody, withdrawn, or depressed including friends and family
fatigue, pelvic pain Uses alcohol or other drugs
Acute complaints genital urinary/ Has stopped seeing friends or has
gynecological (vaginal bleeding, given up favorite activities Sabotages birth control
STIs, UTI, vaginitis, amenorrhea) School problems methods/use
Sleep problems, anorexia, Frequent cancelled appointments Refuses to leave the room
anxiety symptoms (shortness of during health exams
breath, chest pain, palpitations, Delayed care for injuries
hyperventilation, syncope) Seems afraid of partner and fears
Injuries not consistent with breaking up with him/her
history and at different stages of
healing
Psychiatric: depression, PTSD,
anxiety disorders, suicidal
ideation/attempts and substance
abuse
Tools for Screening

While there are many relationship violence screening tools, none are adolescent focused or appropriate. Asking questions
within HEADSSS can help identify signs/symptoms to elucidate ARV:
HEADSSS
Ask questions related to teens relationships (under Sex or Safety)6
I ask all my patients about their relationships. Are you now, or have you ever been in a relationship with
a person who physically hurts or threatens you?
What happens when you and your partner disagree? Does it ever get physical?
Do you feel safe in your relationship/at home?
ADDITIONAL SCREENING QUESTIONS FOR SUSPECTED ARV

Does your partner get jealous when you go out or talk with others?
Does your partner put you down, but then tell you he/she loves you?
Have you been held down, shoved, pushed, hit, kicked, or had things thrown at you by your partner?
Does your partner frighten or intimidate you?
Does your partner make you choose between him/her, or family and friends?
Has your partner forced or intimidated you into having sex?
Are you afraid to break up with your partner because you fear for your personal safety?
6
For a full HEADSSS Assessment refer to the Basics of Adolescent Health Toolkit Module: Adolescent 101

Adolescent Relationship Violence (ARV) cont.
What is the providers role once ARV has been identified?
ASSESS SAFETY INTERVENTION AND REFERRAL
Convey Key Messages.
Are you currently safe where you are now?
No excuse for violence
What has been the worst fight? Were
Not the victims fault
weapons used?
You are not alone
Have you thought about hurting or killing
Changing a relationship can be difficult
yourself or others?
We can find you help and support
Do you have an adult you can confide in?
Utilize a harm reduction approach.
Have you tried to leave your relationship
Inform on resources/safety plan (see resources and safety plan below).
before? If so, what happened?
Empower the youth, point out strengths.
In a crisis/unsafe situation, where would you
Respect what they want to disclose and how (while considering legal
go/who could you turn to for help?
issues re: reporting).
See safety Plan Checklist below.
Educate the victim about ARV (i.e. the cycle of violence).
REPORTING DOCUMENTATION
Reporting depends on state laws. Safeguard confidentiality.
Consider contacting CPS if parents are Document physical injuries (take photographs or describe in detail).
unwilling to protect teen (possible neglect). Detailed documentation is important in case there are court
Reporting mandates are based on age of proceedings but evidence collection can only be cone by a certified
victim. examiner
17 and younger - child abuse report Abuse Centers can help with evidence collection if reporting/
18 and older - domestic violence report pressing charges (e.g. DNA of bite marks, sexual abuse exams photo
mandated in some states documentation).
Safety Plan Checklist

Ensure immediate safety
File necessary reports
Discuss notifying parents (if they dont already know).
Know shelters that take teens
Discuss considering a temporary restraining order (TRO). In most states a minor cannot request a TRO
independently.
Be familiar with counselors knowledgeable with trauma and conflict resolution to help teen negotiate out of a
relationship safely
Advise changing locks/alarms
Urge removing/safeguarding weapons
Resources
The Safe Space teen safety plan worksheet:
http://www.thesafespace.org/pdf/handout-safety-plan-workbook-teens.pdf
National Domestic Violence Hotline 1-899-SAFE
Sources:
1) Foshee VA, Linder GF, Bauman KE, et al. The Safe Dates project: theoretical basis, evaluation design, and selected baseline findings. Amer J of Preventive
Med. 1996; 12(Suppl 2):3947.
2) Avery-Leaf S, Cascardi M, OLeary KD, Cano A. Efficacy of a dating violence prevention program on attitudes justifying aggression. J of Adol Health.
1997; 21:117.
3) Centers for Disease Control and Prevention. Physical dating violence among high school studentsUnited States, 2003. MMWR 2006;55:532-535.

Sexual Assault
Adolescents and young adults are the primary age group at risk for sexual violence.1 Providers play an important role in identifying
instances of sexual abuse or violence experienced by their teen patients. Routine screening for sexual assault should be done at
every visit and providers need to be knowledgeable about the steps to take if a sexual assault is reported by one of their patients.
Fast Facts
Sexual assault is defined as any non-consensual sexual 2/3 to 3/4 of victims of sexual assault knew the perpetrator3
contact that may or may not include rape. This includes More than 40% of adolescent victims report using drugs
sexual touching and fondling. The exact definition varies or alcohol before the assault4
from state to state. 80% of rape victims experience post-traumatic stress
44% of rape victims are under the age 182 disorder5
Recommendations for the Care of Adolescent Sexual Assault Victims6

Providers should:
1. Be familiar with the epidemiology of sexual assault in adolescents.
2. Be familiar with local reporting requirements for sexual assault. Keep in mind that survivors may not want to file a police
report, and the law may mandate filing a child abuse report if they are a minor.
3. Learn about community sexual assault resources and where to refer teen patients for a forensic examination/evidence
collection. Hospitals that have Level 1 trauma units, a rape treatment center, or SANE (Sexual Assault Nurse Examiners),
are usually set up to handle a thorough examination.
4. Screen for a history of sexual assault and potential sequelae
5. Be ready to provide psychological support or counseling referrals to the teen that has been assaulted.
6. Provide preventative counseling to adolescents regarding avoidance of high-risk situations that could lead to sexual assault.
Emphasize the difference between risk and blame, (i.e. even if an individual engages in high-risk situations, it does not mean
they are responsible for being assaulted).
Evidence Collection and Prophylaxis

If patients report sexual assault in the last 72 hours, advise them not to Tips for Supporting Victims of Assault:7
bathe and refer for a forensic examination immediately. Evidence can Validate survivors feelings. Explain that
only be collected within the first 72 hours. Depending on the jurisdiction, what they are feeling and experiencing is
evidence collection will not automatically result in a police report. Most completely normal, acceptable and that
hospitals will hold the evidence for a few months to give survivors time what happened was not their fault.
to decide whether or not they want to file criminal charges. Prophylactic Listen non-judgmentally. Ask survivors what
treatment for Chlamydia and Gonorrhea is recommended and emergency
kind of support they want and need. Honor
contraception is recommended for female victims when indicated. HIV
prophylaxis may be provided with mucosal exposure (oral, vaginal, and respect these needs.
anal). Make sure the survivors are safe and
physically well. If there is an immediate
Resources concern for well-being, create a safety
Rape, Abuse & Incest National Network (RAINN), local plan and/or refer to temporary emergency
rape crisis centers and comprehensive information on housing (particularly when domestic
statistics and related articles violence/intimate partner abuse is also
http://www.rainn.org present).
National Sexual Violence Resource Center, sexual Suggest medical, psychological and/or other
violence organizations in each state assistance, but let them decide which action
http://www.nsvrc.org/organizations to take.
1
Lessing JE. Primary Care Provider Interventions for the Delayed Disclosure of Adolescent Sexual Assault. J of Ped Health Care. Jan 2005.
2
U.S. Department of Justice. 2004 National Crime Victimization Survey. 2004.
3
U.S. Department of Justice. 2005 National Crime Victimization Study. 2005.
4
American Academy of Pediatrics. Care of the Adolescent Sexual Assault Victim. Pediatrics. 2001; 107(6).
5
Ibid.
6
Ibid.
6
San Francisco Women Against Rape. How to Support a Survivor. http://www.sfwar.org/emergency.html.

Sexual Dysfunction
It is important to consider the implications of sexual dysfunction in teens. While data on sexual dysfunction in teens is scarce,
teens experience erectile dysfunction, loss of desire, pain with penetration and other problems that affect sexual function.
Sexual function and dysfunction is a topic area that is often overlooked and it is important to be prepared to provide adequate
guidance to teens who report sexual concerns.
Sexual Dysfunction in Adolescent Females
Forty-three percent of women report experiencing some sort of sexual concern in their lifetime.1 Among these concerns,
younger women report higher frequencies of orgasmic disorders and sexual pain disorders including vaginismus and
dyspareunia, particularly vulvodynia. Change or decrease in libido is a known and common listed adverse reaction to
hormonal contraception, including all combination and progestin-only methods.
VULVODYNIA (AKA VULVAR
FEMALE ORGASMIC DISORDER (FOD)2 VAGINISMUS3
VESTIBULITIS DISORDER)4
Persistent or recurrent delay in, Recurrent, involuntary spasm of Chronic discomfort and burning
or absence of orgasm following a the outer third of the vagina which of the vulva not attributable to
normal sexual excitement phase. interferes with entry of a penis, infection or neurological disorder.
29% of women aged 18-73 finger, tampon, etc into the vagina. Etiology linked to pro-
reported difficulty with orgasm. Estimated 1-6% of women report inflammatory response of the
Can be caused by drugs that symptoms of vaginismus. vestibular mucosa.
increase serotonergic activity: Sexually abused females are more Women who report symptoms
antidepressants, antipsychotics. likely to develop vaginismus of vulvodynia range from 16-80
Younger women report higher The gynecological exam can be years old.
instances of delayed or absent a source of extreme anxiety and 50% of women with vaginismus
orgasm. discomfort for women with this are also diagnosed with
Factors associate with FOD disorder. vulvodynia.
include age, education, religion, Common co-morbidies include
personality, and relationship fibromyaligia, irritable bowel
issues. syndrome and interstitial cystitis.
Sexual Dysfunction in Adolescent Males

Despite a lack of data, sexual dysfunction in adolescent males appears to be common and is generally caused by performance
anxiety and in some cases, condom use.5 Common dysfunctions include premature ejaculation and erectile dysfunction.
Delayed ejaculation is a less common disorder; and is most likely to be caused by psychoactive drugs (see Antidepressant/
SSRI-induced Sexual Dysfunction in Teens on the next page).6
PREMATURE EJACULATION7 ERECTILE DYSFUNCTION8
Persistent or recurrent ejaculation with minimal sexual
satisfaction before, or shortly after penetration and The inability to achieve or maintain an erection.
before the person wishes. Caused by common substances of abuse, many
31% of American men aged 18-59 reported premature psychoactive medications, mental health issues and/or
ejaculation at least once in the last 12 months. physical illness.
Can be caused by psychological factors or underlying 12-32% of college students report erection loss
medical conditions such as pelvic injury, neurological associated with condom use.
disease, prostatic hypertrophy and hypogonandal Most cases of erectile dysfunction in teens are transient.
hypertrophy.
1
Meston CM, Bradford A. Sexual Dysfunctions in Women. Ann Review of Clin Psych. 2007; 3:233-56.
2
Ibid.
3
Ibid.
4
Damsted Peterson C, Lundvall L, Kristensen E, Giraldi A. Vulvodynia. Definition, diagnosis and treatment. Acta Obsetrica et Gynecologica Scandinavica. 2008;
87:9(893-901).
5
Marcell AV, Bell DL. Making the most of the adolescent male health visit Part 1: History and anticipatory guidance. Contemp Pediatrics. 2006; 23:6(38-46).
6
Richardson D, Goldmeier D. Recommendations for the management of retarded ejaculation: BASHH Special Interest Group for Sexual Dysfunction. International
J of STD & AIDS. 2006; 17(7-13).
7
Richardson D, Goldmeier D, Green J, Lamda H, Harris JRW. Recommendations for the management of premature ejaculation: BASHH Special Interest Group for
Sexual Dysfunction. International J of STD & AIDS. 2006; 171-6.
8
Graham CA, Crosby R, Yarber WL, Sanders SA, McBride K, Milhausen RR, Arno JN. Erection loss in association with condom use among young men attending a
public STI clinic: potential correlates and implications for risk behavior. Sexual Health. 2006; 3(255-260).
Sexual Dysfunction cont.
Assessment
Include sexual function in a thorough sexual health assessment (see pg. 13). The extended PLISSIT model is useful for screening
for sexual problems. Conduct a thorough medical history and medication history. Alcohol, tobacco, recreational drugs, some
psychotropic medications, and blockers and many others are all associated with sexual dysfunction in both females and males
(see insert). Review the sexual side effects of medications when prescribing them an assess medication use in the sexual
dysfunction work up.
Interventions ANTIDEPRESSANT/SSRI-INDUCED SEXUAL

Reassurance DYSFUNCTION IN TEENS
Stress reduction techniques SSRI induced sexual dysfunction is not as
Refer the teen to appropriate local resources
well documented in teens as it is in adults.
The low number of cases, however, may be
Ex-PLISSIT9
The extended PLISSIT model takes a stepwise approach to addressing attributed to discomfort surrounding reporting
sexual health concerns. Permission-giving is part of each step and dysfunction to the prescribing health care
reflection and self-awareness are key skills for the provider. When provider or clinicians failing to ask the teen
going beyond levels one and two (Permission and Limited Information) about sexual side-effects.
a greater level of expertise may be required. If this level of care is Tips:
outside the comfort zone of the provider, a referral should be made to Be aware of the side effects of all the
someone more knowledgeable about sexual dysfunction. medications the teen may be taking.
P PERMISSION GIVING: Creates a safe environment to address Always reassure patients of confidentiality
sexual health concerns by screening for a problem. and let them know that they can feel
Ex. Young men and women often have questions and concerns comfortable discussing sexual function at
about sex and how their bodies are functioning during sex do any time.
you have any? Incorporate questions that address sexual
LI LIMITED INFORMATION: Gives the patient limited information function into assessment tools and
about the sexual problem. This is a great opportunity to discuss questionnaires.
causes, normalize and dispel myths about the dysfunction. Refer to the Ex-PLISSIT model for
Ex. Many young men may have trouble getting or maintaining guidance surrounding sexual interventions.
an erection at some point. Sometimes it can happen if a man is Resources for teens:
having problems with his relationship or if he is nervous about http://www.teenwire.com/infocus/2007/if-
having sex with someone. Sometimes men lose their erection 20071106p509-orgasm.php
when they put on a condom. An article geared toward mid to late
adolescents about sexual dysfunction
SS SPECIFIC SUGGESTIONS: Take a problem-solving approach and caused by antidepressants.
make specific suggestions in response to problems discussed.
Source:
Ex. If the teen reports loss of erection with condom use, suggest 1) Scharko AM. Selective Serotonin Reuptake Inhibitor
adding a couple drops of lubricant inside the condom before Induced Sexual Dysfunction in Adolescents: A Review.
J of the Amer Acad of Child and Adol Psych. September
putting it on. 2004; 43:9.
IT INTENSIVE THERAPY: Assess whether or not the primary care
provider can effectively treat the health concern and offer referrals
as required.
Resources for Female Sexual Dysfunction
http://www.obgyn.net/women/women.asp?page=/CPP/articles/Cracchiolo_0499
Symptoms, causes, treatment options, and resources for vulvodynia.
http://www.nva.org/
National Vulvodynia Association. Has links to research articles related to vulvodynia.
http://www.vaginismus-awareness-network.org/index.html
Vaginismus Awareness Network. Has information geared toward providers, partners, and women.
For resources for teens, refer to Click on This, pg. 72.
9
Taylor B, Davis S. Using the Extended PLISSIT Model to Address Sexual Health Needs. Nursing Standard. 2006; 21(11):35-40.

For providers: resources
Counseling Youth About Sexual Function and Pleasure
SEXUAL RESPONSE CIRCUIT IN WOMEN2 Sexual pleasure is an integral part of sexual

Multi-faceted reasons for initiating or agreeing to sex function and behavior and is often not
discussed by healthcare providers. While
Innate desire some providers may feel uncomfortable
Non-sexual rewards/reinforcement discussing the details of sexual pleasure
Emotional intimacy and function, it is an important topic that
Sense of well-being should be discussed with all teen patients.
Maintenance of partner/peer relationships For example, discussing pleasure
Avoidance of abuse promoted with condom use in addition to
safer sex messaging results in increased
Motivation
condom use and safer sex.1
Willingness to engage in sexual interactions
Lack of sexual enjoyment may indicate
Sexual stimuli in an appropriate environment that a teen is not ready to be sexually
Private, safe and comfortable active. Encourage teens to think about
Processing (both physical and psychological) how comfortable they are with their
current sexual behaviors. If a sexual
Awareness of physical sensations of arousal
function problem persists, you may need to
Arousal and Sexual Desire evaluate whether a patient is experiencing
Sense of Satisfaction sexual dysfunction. (See pg. 34).
May or may not include orgasm
TIPS
Improving Female Satisfaction Postponing Male Ejaculation
Encourage use of lubrication as it improves the quality Reassure that this problem diminishes with time.
of sex. Refer her to over-the-counter, water-based Premature ejaculation is very common in adolescent boys,
lubricants. but decreases with age.
Educate young women about their erogenous zones.
Suggest using adequate stimulation. If males perform
Encourage female patients to explore their bodies and
longer foreplay on partner, they are more likely to reach
seek stimulation from erogenous zones: nipples, clitoris,
orgasm simultaneously during sex.
vagina, arms, back, buttocks, ears, feet, fingers, legs, and
neck. Promote condom use. Condom use for hyper-sensitive
Suggest using adequate stimulation. Longer foreplay, males may postpone ejaculation.
oral or manual stimulation of clitoris and other erogenous
zones improves a womans chances of orgasm and/or Recommend finding a safe, private environment and
satisfaction. comfortable sexual position. Awkward environments
Promote condom use. Females report added clitoral may negatively impact male performance.
stimulation when using the female condom and increased
Advise trying kegel exercises. Not all young men
relaxation when stress of potential STIs or pregnancy is
know about their pubococcygeus (PC) muscles and how
reduced.
exercising them can postpone ejaculation. Inform males
Recommend finding a safe, private environment and about anatomy and advise that squeezing PC muscles for
comfortable sexual position. Position is an important seconds at a time will help postpone ejaculation.
factor to consider in maximizing pleasure and minimizing
discomfort. Often youth may be in an awkward Suggest using the Stop and Start method. This
environment, may be rushed or afraid of discovery which involves temporarily pulling out and resuming sex when
can reduce pleasure and satisfaction. feelings of imminent ejaculation subside.
1
Pleasure and Prevention: When Good Sex is Safer Sex. Reproductive Health Matters. 2006; 14(28): 23-31.
2
Basson R. Womens sexual dysfunction: revised and expanded definitions. CMAJ. May 2005;172(10):1327-33.
Safer Sex and Lubrication
FAST FACTS
Lubrication promotes a safer sex experience by decreasing abrasive friction.
Abrasive friction, the result of dry penetration (can include a sex toy) can cause condom breakage or
vaginal and anal tears increasing the chances of transmitting an STI.
Abrasive friction also increases the risk for Herpes outbreaks in those infected.
Using lubrication enhances pleasure during sex.
Lubricants makes sex feel wetter and better.
Dropping a little lubricant in the condom increases sensitivity and erections in adolescent males who have
difficulty maintaining an erection when using condoms.
Dropping a little lubricant outside the condom promotes pleasure for the receptive partner.
Adding flavored lubricant to the outside of condoms promotes a pleasant oral sex experience for both the
giver and the receiver.1
Additives in lubricants such as glycerin can create an environment that is friendlier to yeast infections.
If a teen reports recurring yeast infections, ask about lubricant use and advise to avoid glycerin-based
lubricants.
A Note on Benzocaine: Benzocaine lubricant may have clinical indications (i.e. vulvodynia) but it is not
advisable for anal sex or anal stimulation as it masks the bodys signals of pain and use can result in fissures and
other anal tears.
TYPE OF LUBRICATION PROS CONS

Latex, polyurethane, and nitrile friendly
Can contain parabens and glycerin
Female condom friendly
Water-Based Lubricant Easily washes off skin, clothes or sheets
Cannot be used in water
Astroglide, KY Jelly, etc. Can vary in how long it stays
Easy to rinse off with water
slippery
Sex toy friendly
Oil-Based Lubricant Polyurethane or nitrile friendly (i.e. Cannot be used with latex condoms
Baby oil, Vaseline, hand lotion and female or Avanti condom)1 Not as easy to wash off with soap
mens cream (designed for male Particularly effective for male and water, leaving one susceptible
masturbation), etc. masturbation to bacterial infection
Can be expensive
Must be washed off with soap and
Silicone-Based Lubricant Latex, polyurethane, and nitrile friendly water
Wet Platinum, Eros Body- glide, Stays slippery for a long period of time Harder to remove from clothes or
etc. Can be used in water sheets
Cant be used with some silicone
sex toys
Latex, polyurethane, and nitrile friendly Cannot be used in water
Saliva Free Usually doesnt stay slippery for
Easily washes off skin, clothes, or sheets. long
Resource
http://www.plannedparenthood.org/teen-talk/sex-masturbation/vaginal-oral-anal-sex/got-lube-25408.htm
Planned Parenthoods informational handout for teens on lube.
1
Pleasure and Prevention: When Good Sex is Safer Sex. Reproductive Health Matters. 2006; 14(28): 23 -31.

Safer Sex Toy Use
When addressing the sexual behaviors of adolescents use of sex toys is often not taken into consideration. The use of
sex toys can increase the sexual pleasure of the user, but the different sex toy materials may have implications for the
spread of sexually transmitted infections. For example, porous toys retain bacteria and can transmit infections when
used without a condom while non-porous toys can be thoroughly cleaned and do not retain bacteria.
FAST FACTS1
53% of women and almost half of all men have used a vibrator.
Late adolescent women (age 18-22) represented 15.5% of vibrator users and 30% of women in that age group
have used a vibrator to masturbate.
81% of women and 91% of men who have used a vibrator used it with a partner.
More lesbian and bisexual identified women have used vibrators and dildos compared to heterosexual
women.
Vibrator users scored higher on measures of positive sexual function, reporting higher rates of sexual pleasure
and fared better than their counterparts when considering natural lubrication, pain and erectile function.
Sex Toy Guidelines for Safety and Minimizing Infection of Viruses, Bacteria, or Yeast:
Sex toys should be thoroughly cleaned and dried after each use.
Condoms should be used when sex toys are:
Shared between partners.
Used vaginally and anally and the condom should be changed when switching from anal to vaginal
penetration.
Made out of porous materials such as jelly rubber and soft skin.
Some silicone and silicone blend toys are porous and cannot be used with silicone lube. Advise patients to read
labels to be sure.
If recurring infections occur, ask about sex toy use and advise on safer practices.
ANAL TOYS SHOULD ALWAYS HAVE A FLARED BASE TO PREVENT IT FROM GETTING STUCK IN THE RECTUM.
MATERIAL OF TOY CLEANING RECOMMENDATIONS SAFER SEX TIPS

Use a condom when sharing the toy or
Glass Mild liquid soap and warm water when using the same toy vaginally and
Non-porous
anally.
Silicone Anti-bacterial soap and warm water;

rinse well and dry thoroughly or Use a condom when sharing the toy or
Usually non-porous (can
when using the same toy vaginally and
vary in porosity the product Dishwasher or
anally.
is if it is not 100% silicone) Boil to disinfect
Elastomer and Vinyl Always use a condom whether or not the

Mild liquid soap and warm water
(Less Porous) toy is being shared.
Jelly Rubber, Polyvinyl Mild soap and hot water or a washcloth

Always use a condom whether or not the
Chlorides for non-waterproof vibrators; remove soap
toy is being shared.
(Porous) residue before next use
1
Herbenick D, Reece M, Sanders S, et al. Prevalence and Characteristics of Vibrator Use by Women in the United States. J of Sex Med. 2009; 6(7): 18571866.

Pregnancy Prevention Options
METHOD PROS CONS
Requires no supplies.
Natural. Requires motivation and self-control from
Abstinence Only definite way to prevent both partners.
pregnancy/STIs.
Unreliable.
Requires motivation and self-control from
both partners.
Requires no supplies.
Withdrawal Difficult for male to predict ejaculation
Natural.
No control by women need to rely
completely on men to prevent pregnancy.
Poor protection against STIs.
Immediate protection.
Easily accessible. Requires planning.
Condoms Protects against pregnancy/STIs. Both partners must be cooperative.
Male partner can last longer when Partner may be allergic to latex.
using a condom.
Requires fitting and continued use.
Can be expensive if not covered by
Cervical Cap/ Some protection against STIs. insurance.
Diaphragm Non-visible. Best used when intercourse can be predicted.
Must be comfortable inserting/removing.
Not usually popular among teens.
Much more effective with condom or
diaphragm use.
Requires planning.
Spermicides Easily accessible.
No protection against STIs.
May increase risk of contracting Gonorrhea
or HIV through irritation of vaginal mucosa.
Side effects such as nausea and vomiting if
using OCPs, but levonorgestrel only (Plan B)
is well tolerated.
Effective and safe for teenagers.
Emergency Should be taken ASAP, but reduces
Back-up method for unprotected
Contraception pregnancy risk up to 120 hours after
intercourse.
(not intended to be a intercourse.
Reduces pregnancy risk after
regular form of birth Menstrual period is disrupted (may come
control) unprotected or under-protected
earlier or later than usual).
intercourse.
Less effective than regular hormonal
contraception.
Side effects such as thinning hair,
Non-visible. depression, weight gain and irregular periods
Only requires injection every 12 weeks. may be especially bothersome to teens.
Progestin only Many stop getting their period Impacts bone mineral density with use over
Injectables (Depo- during use. time (see pg. 23).
Provera)
Helps protect against uterine cancer. Can be costly without insurance coverage.
Highly effective with proper user Re-injection must be timely.

Pregnancy Prevention Options cont.
METHOD PROS CONS

Requires consistent daily use.
Forgetfulness increases failure.
Few contraindications. Break through bleeding worries and upsets
Safe use after menarche. many teens.
Oral Contraceptives May improve acne, dysmenorrhea No protection against STIs.
(Birth Control Pills)
and cycle control. Might cause nausea, breast tenderness,
Highly effective with proper use. moodiness, and weight gain.
Contraindicated for migraines with auras.
Can be costly if not covered by insurance.
Requires inserting new ring every 4 weeks.
Non-visible. The ring stays in for 3 and is taken out for 1
Vaginal Ring (Nuva Highly effective with proper use. week.
Ring) Does not require consistent daily Must be comfortable inserting/removing ring.
use. Contraindicated for migraines with auras.
Requires applying a new patch once a week
for 3 out of 4 weeks.
Highly effective with proper use. Visible particularly on people of color.
Birth Control Patch Does not require consistent daily Side effects include breast tenderness and
(Ortho Evra)
use. nausea.
Contraindicated for migraines with auras
Good for 3 years. Must be inserted/removed by a provider.
Barely visible. Side effects may include headaches, irregular
Hormonal Implant Highly effective. bleeding patterns and arm discomfort
(Implanon)
Capsule can be removed any time. (initially post-insertion).
May cause light to no periods. No protection against STIs.
Slightly higher expulsion rate in nulliparas.
Non-visible.
Not recommended for teens with a high risk
Minimal maintenance is needed.
for contracting CT/GC.
Very effective against pregnancy.
Must be screened for STIs prior to insertion.
Intra-Uterine Device Levonorgestrel IUD lasts for 5 years, Copper IUD sides effects include menstrual
(IUD) the copper IUD lasts for 10 years.
cramping, longer and/or heavier menstrual
Levonorgestrel IUD lessens
periods and spotting between menstrual
menstrual flow and can be used to
periods.
treat heavy periods.
Pg. 57 includes a brief chart to distribute to teens about different types of contraceptives. See pg. 22 for tips
for talking with teens about contraception and sexual health.

Menstrual Suppression
As dedicated products for menstrual suppression become more available and gain popularity, more women are interested
in learning how they can suppress menstruation. Extended cycling of the combined hormonal birth control methods to
suppress menstruation is comparable in safety and effectiveness as the traditional birth control regimen.1
FAST FACTS
The average modern women will have four times as many lifetime periods as pre-agricultural women.1
Monthly bleeding with combined hormonal contraceptive use is not a true period. This withdrawal bleeding
is the bodys reaction to not having a sustained level of hormones.
Off label extended cycling was used for years before the first dedicated product was approved by the FDA
in 2003.3
Most adult women consider menstruation to be an inconvenience.4
1
Clinical Proceedings: Extended and Continuous Use of Contraceptives to Reduce Menstruation. ARHP/NPWH. September 2004.
2
New Yorker, 2000
3
Steinauer, et al 2007
4
Clinical Proceedings: Extended and Continuous Use of Contraceptives to Reduce Menstruation. ARHP/NPWH. September 2004.
Extended Hormonal Contraception

Extended hormonal contraception used to delay or eliminate menstruation provides many menstrual and non-menstrual
benefits to users.2
MENSTRUAL BENEFITS NONMENSTRUAL BENEFITS
Reductions in: Reductions in:
Dysmenorrhea Menstrual migraines
Menorrhagia Endometriosis
Premenstrual syndrome Acne
Irregular monthly periods Improved sense of well-being
Extended cycling is most often recommended in adult women and teens for:3
Inducing amenorrhea for a specific event
Women in the military
Accommodating patient preference for fewer menses
Managing menses related problems such as dysmenorrhea, menorrhagia, cyclic headaches
Managing problematic menses in women with developmental and/or physical disabilities or behavioral
problems
Extended Methods4
METHOD USE
Extended or continuous use with elimination of the placebo pills
Combined oral contraceptives
Can use multiple packs or dedicated products
Vaginal contraceptive ring* Extended or continuous use
Transdermal contraceptive patch* Extended or continuous use
*Currently, there are no FDA recommendations for the use of the vaginal ring or transdermal patch.
1
Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception. 2003; 68:89-96.
2
Sulak PJ, Kuehl TJ, Ortiz M, Shull BL. Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone with-
drawal symptoms. Amer J Obstet Gynecol. 2002; 186:1142-1149.
3
Gerschultz KL, Sucato GS. Eliminating monthly periods with combined hormonal contraception. Womens Health. Sept 2007; 3(5):541-5
4
Anderson FD. Contraception. 2003. Kaunitz AM. Contraception. 2000. ARHP. 2003. NuvaRing Product Information. 2001. Stewart FH. Obstet Gynecol. 2005.
Kwiecien M. Contraception. 2003. Sulak PJ. Amer J Obstet Gynecol. 2002.

Menstrual Suppression cont.
Menstrual suppression can also occur with long term use of progesterone contraceptive methods including the
levonorgestral intrauterine system (Mirena) and the depot medroxyprogesterone injection (Depo-Provera). For more
information on prescribing considerations for these methods, see pg. 22.
PRESCRIBING CONSIDERATIONS1,2
Clarify clients expectations for withdrawal bleeding
Frequency
Predictability
Use monophasic pills or dedicated products
Keep it simple and straightforward
Start with 3 21/7 (conventional) cycles if history of heavy bleeding
Discuss cost of extra pills (up to 4 cycles extra per year); most insurance plans will not cover extra cycles
Extended regimen as effective in preventing pregnancy as conventional OCs
Withdrawal bleeding is comparable to a conventional withdrawal bleed
Frequency of breakthrough bleeding (unscheduled bleeding episodes) initially higher with extended OC
regimen but declines over time
One study has shown that frequency of sustained amenorrhea may be lower in patients using the extended
use of the transdermal contraceptive patch3
No endometrial pathology noted
Nonmenstrual side effects are comparable to conventional dosing
1
Sucato GS, Gold MA. Extended cycling of oral contraceptive pills for adolescents. J Ped Adol Gyn. Dec 2002;15(5):325-7.
2
Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral contraceptive. Contraception. 2003; 68:89-96.
3
Stewart FH, Kaunitz AM, LaGuardia KD, et al. Extended Use of Transdermal Norelgestromin/Ethinuyl Estradiol: A Randomized Trial. The Amer College
of Obstetricians and Gynecologists. 2005; 105(6).
Common Patient Questions and Concerns5

Is it safe to use hormonal birth control continuously?
Taking the birth control pill continuously is not any riskier than taking monthly birth control pills. Studies have also
shown that use of Seasonale, the dedicated product, did not cause any health problems in users. If you have high
blood pressure or a history of problems with blood clots you may not be able to use birth control pills.
How often do I need a period?
Women who are on hormonal birth control pills do not need to get a period ever. In fact, the bleeding that occurs
when you are on the pill isnt even a real menstrual period.
What should I do if I have spotting?
Spotting is normal as your body gets used to the new hormone levels. Spotting can happen on and off in the first
months, sometimes longer. If your spotting becomes heavy or doesnt stop after the first few months, call your
healthcare provider.
How will I know if I am pregnant?
If you take your birth control pills correctly, pregnancy is very rare. If you start to feel any abnormal symptoms
like breast tenderness, feeling overly tired, and nauseated, you may want to take a pregnancy test. You can either
schedule an appointment for a pregnancy test with me or buy one from the drug store.
5
Clinical Proceedings: Extended and Continuous Use of Contraceptives to Reduce Menstruation. ARHP/NPWH. Sept 2004.

Establishing Paternity and Paternity Laws
Many teens do not know the laws about paternity or what paternity implies. Generally, paternity is presumed if the
parents are married. However, if the parents are not married, paternity needs to be established. Paternity can legally
impact a lot of things; and, depending on the relationship between the mother and the father, establishing paternity can
either be an appropriate or inappropriate choice.
Pros and Cons to Establishing Paternity

PROs CONs
Can request custody Establishing paternity may compromise the safety of the
Can request child support mother and the child in the following situations:
Inheritance If physical, emotional or sexual abuse of the mother
Eligibility for fathers insurance benefits is suspected
Can obtain fathers medical history If the pregnancy is a product of rape
Usually a child wants to know the identity of his/her If coercion is suspected
father. If the father is involved in criminal activity
Despite the fact that unmarried parents are not legally required to establish paternity, young parents may be inappropriately
pressured to establish paternity before leaving the hospital or in order to be eligible to file for social services. Encouraging
both married and unmarried teen patients to think about paternity before the child is born can help prevent teens from
making uninformed decisions about paternity and long-term implications if established. Refer teen parents to local legal
counsel organizations to receive guidance on paternity laws.
Testing Paternity: Blood and DNA Testing

A parent may request blood or DNA testing when paternity is ambiguous or being contested. In
other situations, if the mother is applying for social services or benefits, the state may require
that paternity be determined with a DNA test before benefits are awarded. When faced with the
question of paternity testing, however, it is often unclear who is financially responsible for the test
and this responsibility can vary state to state.
TIPS:
While the healthcare providers role may be relatively limited in this matter, it is important to
know the correct referrals and resources in your area.
Contact local legal aid or other public counsel option.

Contact the local court. Generally it is the court that may force paternity testing and often
determine who will pay for the test.
RESOURCE:
http://family.findlaw.com/paternity/paternity-tests.html
This site outlines basic information on paternity testing.
Sources:
1) http://family.findlaw.com/paternity/chronology-establishing-paternity.html
2) Weisz AG, Gudeman R, Sartell M, Ramos A. Legal Issues for Pregnancy and Parenting Teens in California. Stuart Foundation; 1997.

HPV Vaccine
The quadrivalent HPV vaccine types 6, 11, 16, 18 (GARDASILTM, manufactured by Merck and Co., Inc.) is licensed for use among
females and males aged 926 years for prevention of vaccine HPV-typerelated cervical cancer; cervical, vaginal and vulvar
cancer precursors; and anogenital warts. Currently its use in males is optional and at the discretion of providers. The bivalent
HPV vaccine types 16, 18 (CervarixTM, manufactured by GlaxoSmithKline) was recently licensed for use among females aged 1025
years for prevention of vaccine HPV-typerelated cervical cancer; and cervical, vaginal and vulvar cancer precursors.
Recommendations for use of HPV Vaccine:

OPTIONAL VACCINATION OF MALES AGED 9-26 YEARS
Currently (10/2009) the HPV quadrivalent vaccination in males is optional and at the discretion of providers. There are no
recommendations for the use of the bivalent HPV vaccine in males.
ROUTINE VACCINATION OF FEMALES AGED 1112 YEARS
Ideally, the vaccine should be administered before sexual debut and subsequent potential exposure to HPV through sexual
contact.
Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of females aged 11 12 years with 3
doses of quadrivalent or bivalent HPV vaccine.
The quadrivalent vaccination series can be started as young as age 9 years and the bivalent as young as 10 years.
CATCH-UP VACCINATION OF FEMALES
The quadrivalent is also recommended for females aged 1326 years who have not been previously vaccinated or who have not
completed the full series, the bivalent is recommended for females aged 1325 years who have not been previously vaccinated
or who have not completed the full series. The American Cancer Society states there is no evidence of benefit for vaccinating
the general population after the age of 19 years.
Sexually active females who have not been infected with any of the HPV types included in the vaccine would receive full
benefit from vaccination.
Vaccination provides less benefit to females if they have already been infected with one or more of the HPV types included in
the vaccine. However, females in this age bracket should still receive the vaccine regardless of potential exposure since there is
no cost effective way to determine previous exposure to the different HPV types.
DOSAGE AND ADMINISTRATION
The vaccine should be shaken well before administration.
The dose of quadrivalent HPV vaccine is 0.5 mL, administered IM, preferably in the deltoid muscle.
RECOMMENDED SCHEDULE
Both the bivalent and quadrivalent HPV vaccines are administered in a 3-dose schedule.
The second and third doses should be administered 2 and 6 months after the first dose.
MINIMUM DOSING INTERVALS AND MANAGEMENT OF PERSONS WHO WERE INCORRECTLY VACCINATED
The minimum interval between the first and second doses of vaccine is 4 weeks.
The minimum recommended interval between the second and third doses of vaccine is 12 weeks.
Inadequate doses of quadrivalent or bivalent HPV vaccine or vaccine doses received after a shorter-than-recommended dosing
interval should be readministered.
INTERRUPTED VACCINE SCHEDULES
If the quadrivalent or bivalent HPV vaccine schedule is interrupted, the vaccine series does not need to be restarted.
If the series is interrupted after the first dose, the second dose should be administered as soon as possible, and the second and
third doses should be separated by an interval of at least 12 weeks.
If only the third dose is delayed, it should be administered as soon as possible.
Resources for Patient & Parent Education:
The Center for Disease Control (CDC) has excellent handout resources that explain the current understanding about HPV and
cervical cancer, the function of Pap screening tests, HPV prevention, and information about the HPV vaccine.
HPV: Prevention & Abnormal Pap Results PDF Handouts
http://www.cdc.gov/std/hpv/common
HPV Vaccine: Fact sheets & Information
http://www.cdc.gov/std/hpv/
http://www.cdc.gov/std/hpv/common-clinicians/InsertParents.pdf

For Youth
Sex, Virginity & Abstinence

People have sex for many reasons to feel close to their partner, to show and receive affection, and to experience
the physical pleasure of sex. There are also many reasons that people choose not to have sex religious beliefs, they
dont feel ready, or they have not found the right person yet. In the end, it is always your decision to have sex or not
have sex, the first time and every time after.
Here are some common sexual behaviors

Masturbation - touching yourself in a sexual way. Partners can masturbate together and watch each
other.
Finger Sex - touching your partners sexual organs with your hands.
Sex talk or talking dirty - people saying things to each other about sexual feelings, fantasies, and acts.
Sex talk can be used during sexual touching or intercourse.
Phone sex - people talk sexually to each other over the phone.
Anal intercourse - a penis, finger, sex toy, or other object is put inside the anus.
Vaginal intercourse - a penis, finger, sex toy, or other object is put inside the vagina.
Oral sex - a mouth or tongue is used to sexually stimulate someone. The tongue is used on the penis,
scrotum, clitoris, vagina, anus, etc.
Other Important Terms
Abstinence some people use the word abstinence to refer to
not having sex. They may mean that they are not doing any
Am I a Virgin? sexual activities with another person at all. It can also mean that
Virginity refers to never having they are doing some sexual activities, just not having vaginal
had sex. For some people, being intercourse.
a virgin means someone has not
Periodic Abstinence when someone decides to take a break from
done any sexual activities with
sex. People can decide to take a break from sex for a few days or
another person. For others, being a
a few years.
virgin just means that someone has
not had vaginal intercourse. Sexual Self-Reliance when you rely on yourself to make yourself
feel sexually satisfied. This is often through masturbation. Rely-
Myths and Facts about Virginity ing on yourself is different from relying only on a partner for
There is a virginity test. sexual pleasure. You can use self-exploration and masturbation
Myth! There is no medical test to get to know your body and show your partner what you like.
to tell if you are a virgin. Being sexually self-reliant can also make sex with someone else
better.
If a girl breaks her hymen, she
can still be a virgin.
Fact! The hymen, also known as the cherry, is a thin tissue that covers the vaginal opening. This
tissue can break from sexual or non-sexual activities. These non-sexual activities could be riding a
bike or climbing a tree.
You can tell if someone has had sex by the way he or she looks or acts.
Myth! You cannot tell if someone is sexually active by how he or she looks or acts. Everyone is dif-
ferent.

For youth
Having Sex on Your Own Terms

QUIZ: Do You Have to Say Yes to Sex If
you have already lost your virginity? someone is a teacher, policeman, or boss at your
you have had sex with someone before? job? That person has power over you?
someone spends money on you? someone is in your family?
you are a female and your cleavage is showing? someone is really popular and wants to have sex?
your clothes are tight fitting? you are wearing a someone is older than you and wants to have sex?
short skirt? you are a female and it is late at night?
you are a male and want to be a real man? your you are a female and you are naked in bed with
friends say you need to have sex to be a man? your partner?
your partner is really horny? you are a male and a 15-year-old virgin? 17? 19?
you want someone to like you? you have been raped, or forced to have sex before?
you are a female and you have been called a ho? you are at a place you shouldnt be?
whore? slut?
you have been drinking or smoking?
you are a straight male and a female is offering?
you love sex and think it feels good?
someone is your boyfriend or girlfriend?
The answer to all of these questions is NO.

YOU NEVER HAVE TO SAY YES to sex. Sex is always a choice, the first time and every time!
AND REMEMBER: Sex is something YOU CAN SAY YES to when you and your partner are ready, feel safe
and comfortable with each other, and are using protection against pregnancy and STIs
Thinking about having sex? Ask yourself these questions Tips for Having Sex on Your Own Terms:
Am I in a healthy, trusting, respectful and honest relationship? Always have a safe way to get home
Do we treat each other as equals and communicate well? when on a date or out with friends.
Do my partner and I agree on the nature of our relationship Pick friends you can trust. A true friend
(friendship, steady romantic relationship, etc.?) will respect your sexual decisions.
Do we have the same ideas about sex and love? Be prepared with a safer sex method.
Can I explain my decision to have sex if parents or friends Get condoms or talk to your provider about
ask why? picking a birth control method before you
start having sex.
Is having sex my idea, or am I being pressured? Is having
sex something my partner really wants, or am I pressuring Get tested for STIs. Go to the clinic with
him or her? your partner before you have sex.
Am I OK talking with my partner about what I do and dont Ask your partners about their sexual
want to do sexually? desires. Be sure to share your own desires,
too. Your sexual decisions should be what
Do I know how to use birth control and condoms to prevent you both want, every time.
pregnancy and STIs?
Pay attention to your partner. If he or she
If sex leads to pregnancy or getting an STI: Do I know seems unsure always stop and ask, Is this
where to get treated for an STI? Do I feel ready to make de- OK?
cisions about a pregnancy? Will my partner be there for me?

For Youth
The following are some tips for deciding what you should look for in a relationship. These should also help you know
when you are in an unhealthy relationship. Healthy dating and sex habits now lead to healthy sex and dating habits in
the future. If you think you might be in an unhealthy or abusive relationship, talk to a trusted and caring person in your
life. Most people need support when they are in these situations.
The Relationship Bill of Rights
I hereby declare that I have the right to...
- Trust my feelings.
- Be with who I want, when I want, and how I want.
- Say NO or leave a situation if I feel uncomfortable.
- Disagree with my partner.
- Have sex when my partner AND I both want to.
- Have sex that feels good to me.
- Feel good about myself whether I am in a relationship
or not.
- Accuse someone of hurting me physically or
sexually.
- Receive emotional support and understanding.
- Control my own future.
Resources/Links:
Advocates for Youth: http://www.advocatesforyouth.org/
youth/health/relationships/index.htm
Planned Parenthood: http://www.plannedparenthood.org/
health-topics/relationships-4321.htm
Planned Parenthoods Teenwire: http://www.teenwire.com/
topics/relationships-friends-and-family.php

For youth
The Relationship Spectrum

Healthy Unhealthy Abusive
A HEALTHY AN UNHEALTHY AN ABUSIVE
RELATIONSHIP RELATIONSHIP RELATIONSHIP
A healthy relationships means that You may be in an unhealthy An abusive relationships starts
both you and your partner are... relationship if one of you is when one of you...
Communicating - You Not communicating Communicates in a way
talk openly about problems - When you talk about that is hurtful or insulting.
and listen to one another. problems you fight, or you
You respect each others dont talk about them at all. Mistreats the other - One
opinions. or both partners does not
Disrespectful - One or both
respect the feelings and
Respectful - You value each of you is not considerate of
physical safety of the other.
other as you are. each other.
Not trusting - You dont Accuses the other of
Trusting - You believe what believe what your partner flirting or cheating when
your partner says. says. its not true - The partner
Honest - You are honest Dishonest - One or both that accuses may hurt the
with each other but can still partners is telling lies. other in a physical or verbal
choose to keep certain things Trying to take control way as a result.
private. - One or both partners feel
Denies that the abusive
Equal - You make decisions their desires and choices are
actions are abuse - They
together and hold each other more important.
may try to blame the other
to the same standard. Feeling crowded or not for the harm theyre doing.
spending time with others
Enjoying personal time
- Only spending time with Controls the other -
- You both enjoy spending
your partner. There is no equality in the
time apart and respect when
relationship. What one
one of you needs time apart. Pressured by the other
into sexual activity - One partner says goes.
Making mutual sexual partner tries to convince the
choices. You talk openly other that they should have Isolates the other partner
about sexual choices sex, or more sex. - One partner controls
together. You both consent where the other one goes,
Ignoring the consequences and who the other partner
to sexual activity and can
of sex - The partners are sees and talks to.
talk about what is ok and
having consensual sex
what isnt. You discuss
with each other but are Forces sexual activity -
using condoms or other birth
not talking about possible One partner forces the other
control methods.
consequences. to have sex.
Adapted with Permission from CORA (Community Overcoming Relationship Abuse). http://www.teenrelationships.org; 24 hour hotline 800.300.1080

For Youth
Love Shouldnt Hurt

Dating and being in a romantic relationship can be fun and exciting. Unfortunately, too many teens are hurt
by the people they date. Dating or relationship violence is a pattern of violence someone uses against their
boyfriend, girlfriend, or date and it includes emotional, verbal, physical, and sexual abuse.
Quiz: Are you In an Abusive Relationship?

1. Are you afraid of your partner or afraid of what your partner will do if you end your relationship?
2. Does your partner call you names, make you feel stupid, or tell you that you cant do anything right?
3. Is your partner extremely jealous?
4. Does your partner try to limit where you go or who you talk to?
5. Do you feel cut off from your friends or family because of your partner?
6. Do you feel threatened by your partner if you say no to touching or sex?
7. Has your partner ever blamed you for his/her violent actions?
8. Has your partner ever shoved, hit, kicked, held you down, or physically hurt you on purpose?
9. Is your partner really nice sometimes and really mean other times as if she/he has 2 different person-
alities?
10. Does your partner make frequent promises to change and never hurt you again?
If you answered YES to any of the above questions, your partner is being abusive towards you. It is
very important for you to be safe and reach out for help.
Safety Tips: Where to Go for Help:

Do not meet or hang out with the abusive Educate yourself about dating/relationship vio-
person by yourself. Go to a public place or lence. Search for information on the internet or at
a location where your family or friends are your local public library.
nearby. Talk with your parent, family member, teacher,
Avoid being alone at school, at work, or on counselor, doctor/nurse, clergy member, or other
the way to and from places. trusted adult. The less isolated you are, the less op-
Always tell someone you trust where you are portunity the abusive person has to hurt you.
going and when you will be back. Seek help from professionals. Go to places such as
Make sure you can get home or get to a safe school health centers or counseling offices, clin-
place on your own. Bring your own car, ics, youth or faith-based organizations, community
money for the bus or taxi, or go to a public centers and/or call a hotline.
place and call friends/family for a ride.
Memorize the addresses and phone numbers Resources:
of people you trust. Go to these people for National Teen Dating Abuse Helpline:
help if your date or partner becomes violent 1-866-331-9474
or abusive. Call 911 if you are in an emer-
Rape Abuse Incest National Network:
gency situation.
1-800-656-HOPE
You deserve healthy relationships! Love is Not Abuse: www.loveisnotabuse.com
Source:
Washington State Office of the Attorney General. Teen Dating Violence Brochure. 2004, http://www.atg.wa.gov/violence. Adapted and reproduced with permis-
sion.

For youth
Wetter Makes It Better

Did You Know???
Lube can make condom use more pleasurable for both sexual partners
Lube can decrease pain and discomfort from dryness and friction during sex
Lube can prevent condoms from breaking
Lube can be put on the inside of a condom before rolling it down the penis, and on
the outside of a condom before having sex
Got Lube?
VAGINAL LUBRICATION:
The vagina gets wet or lubricated when ANAL LUBRICATION:
sexually stimulated The anus does NOT get wet or lubricated
If the vagina does not get wet enough when sexually stimulated
before a finger, penis, or sex toy is inserted, Lube should always be applied to the
it can be painful or irritating opening of the anus and on the finger,
Lube can be put on the opening of the penis, or sex toy that is inserted into the
vagina and on the outside of a finger, anus to increase pleasure and decrease
penis, or sex toy before inserting into the pain, friction, and tearing of the anus
vagina to increase pleasure during sex Sometimes you need to reapply lube
Sometimes you need to reapply lube
What Type of Lube Should I Use?

Always use water-based lubricants with pre-lubricated
latex condoms. Common types of water-based lubes
include Astroglide and K-Y Jelly
If you or your partner are irritated by a lubricant, stop
using it and try one that does not contain parabens or
glycerin. Check the labels!
Forgot To Pick Up
The Lube?
If you or your partner are irritated by latex condoms, try Use plenty of saliva
using polyurethane condoms instead (spit)! Its free and always
available!
Do NOT use oil-based lubricants (baby oil, lotion, Olive oil,
or Vaseline) with latex condoms. Oil-based lubricants
can cause condoms to break

For Youth
Be Safe With Sex Toys

Keep them clean. Toys are made from all different types of materials. They can be really hard to clean or really
easy to clean. Follow the directions on the labels for cleaning and storing. Dry your toys well after you clean
them.
Know the difference between sex toy materials:
Easiest to 100% silicone - Can be washed with antibacterial soap or in a dishwasher.

Clean
Easy to
Glass - Can be washed in mild liquid soap and warm water.
Clean
Hard to Elastomer and Vinyl - Bacteria remain after its washed in mild liquid soap and warm
Clean water.
Hardest to
Jelly Rubber and Polyvinyl Chlorides (PVC) - Bacteria remain after its washed in mild
Clean liquid soap and warm water.
Always use a condom when using sex toys with a partner and when they are hard to clean.
Remember to put on a new condom when you are:
Done using a toy and want to share it with a partner
Going from one hole to another (especially from anus to vagina)
Read labels. Avoid toys that have substances like phthalates. Look for phthalate-free toys.
They are safer for your health.
Only use toys that are flared at the bottom for anal sex. This way, it wont get stuck.
What if you dont have time or money to buy sex toys?

Cucumbers, carrots, and bananas (with the peel) make great dildos. Just remember to use a condom!

For youth
Sex, Technology & You
So, You Met Someone Online...

Some questions to ask yourself are:
1. Does their story stay the same about their age and
background?
2. If sex is brought up, are they respectful about it?
3. Are they ok when you say you dont want to give out personal
information? Are they ok when you say you dont want to meet
face to face?
If YES, these are some of the signs of a healthy relationship - online.
If NO, then you may want to consider meeting other new people.
sending a naked
DID Y O U K N O W
al?
e can be illeg
pictur e a n d te xt messages.
You can
st o n li n al text
d e s p ic tures you po g o r re c e iving a sexu
This in c lu nd in But
b le w it h th e law for se to so m e o n e you trust.
get in trou ay send you
r picture rgument.
e . Y o u m g a b re a k up or an a
mess a g dd u ri n u press
ic tu re s a re forwarde ig h t e n d u p before yo
some p r picture m
t where you
Think abou
SEND.
Tips for Keeping Your Information Private

Make sure your messages are private. Add this at the end of your e-mail: This email message and any
files transmitted with it are private and intended only for the individual to whom they are addressed.
Prevent IM forwarding. Set your chats to off the record. This
means no record of your conversation will be saved. Keep in mind
that a text can still be copied and pasted.
If you want to make sure that your text is private, send anonymous
messages through services such as www.anontxt.com.
Use a screen name different from your real name when in chat
rooms.
Check out the privacy settings for your social networking site. You
can control who can see your profile. Also, never post your phone
number or address so it can be seen publicly.

For Youth
Am I Normal? A Tour of The Female Genitals

Female Genitals KEY TERMS
Pubic Hair - hair that surrounds
Pubic Hair the sex organs for protection.
Clitoris
Labia Majora - also called the
outer lip. Pubic hair grows
Urethra here.
Labia Minora - also called the in-
Hymen ner lip. It may vary in texture,
Labia Majora size and color. It covers the
urethra and vaginal opening.
Vaginal
Opening Clitoris - the pleasure center of
Labia Minora the vulva. It is a tissue that fills
Anus with blood and becomes erect
when sexually aroused.
Urethra - a tube that carries your
urine, or pee, to your urethral
Diagram reproduced with permission from www.Avert.org opening. It is a tiny hole under
the clitoris.
Fact Check: Female Genitals
Hymen - the thin layer of tissue
Female genitals come in different sizes, colors and shapes.
that covers the vaginal open-
The vagina releases discharge to keep itself clean and ing. The hymen can break at
healthy. Everyone has a natural smell that is different. any time in many different
ways.
Some families decide to circumcise (remove parts of the fe-
Vaginal Opening - the passage
male sex organs). Some people think this is OK for cultural
from the uterus to the outside
reasons. Others think its violent and should be stopped.
of the body. Contains the plea-
This practice can cause problems with sex, hygiene, and
sure center called the g-spot.
childbirth.
Anus - the opening of the rec-
tum where waste leaves the
body.
How to Keep your genitals healthy:
Wear cotton underwear and change them every day.
Wipe from front to back.
Wash with warm water and mild soap. Resources

http://www.scarleteen.com/
Avoid douching.
article/body/anatomy_pink_
Try to learn what your genitals look like. If you notice anything parts_female_sexual_anatomy
thats not normal (lumps, bumps, changes in discharge) let your http://www.advocatesforyouth.
healthcare provider know.
org/storage/advfy/documents/
leaders_hygiene.pdf

For youth
Am I Normal? A Tour of Male Genitals

KEY TERMS
Male Genitals Pubic Hair - hair that surrounds
the sex organs.
Penis - the male sex organ that
Pubic Hair is made up of the glans and the
shaft.
Shaft - the long part of the
penis below the glans. It grows
longer when sexually aroused.
Glans - the tip or head of the
penis. At the tip of the glans
Shaft is the urethral opening. The
urethral opening is a small
Penis opening that releases urine,
semen, and pre-ejaculate
Testicle fluid..
Testicles - reproductive
glands that make sperm and
Glans testosterone. They are covered
Testicle by a loose skin called the
scrotum.
Diagram reproduced with permission from www.Avert.org
Fact Check: The Male Genitals How to Keep Your genitals Healthy:
Wear clothes that fit loosely. This prevents
Male genitals come in different Jock Itch, irritation or chapping in the geni-
sizes, colors and shapes. tal area.
Penises can change a lot in size. If you play sports, wear an athletic supporter
to protect your sex organs.
They can go from flaccid (soft) to
erect (hard). Wear cotton underwear and change them
every day.
Some penises are circumcised. Wash with warm water and mild soap.
Circumcision is when the foreskin
If you are uncircumcised, gently pull back
or loose skin that covers the glans of the skin on the head of your penis. Wash
the penis is cut. Parents often decide that area with soap and water.
whether or not to circumcise their
Try and learn what your genitals looks like.
boys. If you notice anything thats not normal
(lumps, bumps, changes in discharge) let
your healthcare provider know.

For Youth
What to Expect at Your First Womens Health Exam.

As you get older, your provider may tell you that you need a gynecological or pelvic exam. This means that he
or she will take closer look at your reproductive system. You may need this exam if you...
are sexually active and have symptoms of an infection
have any changes or questions about your sexual health
have never had a gynecological exam and are 21 years of age or older
you are pregnant
dont start your period or stop having your period
Your provider will ask questions about your period. He

or she will also ask about sex, pregnancy and STIs. Its Some Tips
important to answer these questions truthfully. The provider Come prepared to this visit by knowing
will not tell anyone what you tell him or her unless he thinks the dates of your very first period and
that someone has hurt or abused you. your last menstrual period.
You will undress and cover up. You will probably be left
alone in the room to undress and cover up with a sheet or
Do not come when you are on your
period unless you are having a discharge,
a gown. burning when you pee, abdominal pains
or irregular bleeding.
You will lie on the exam table and will be asked to scoot
to the edge of the table and open your legs. Usually you
It is your right to ask for a different
provider if you do not feel comfortable
will be asked to put your feet in foot rests that will help
with the one you have, or ask for a female
keep your legs apart while the exam is done. If you have
to be in the room if you have a male
mobility problems, use a wheelchair, or have tight legs,
provider.
your provider will work with you to find a comfortable
position. There are usually three parts of the exam: It is almost always ok to bring someone
External Exam The provider looks at the outside into the exam room with you, like a
of your vulva for bumps or other problems. relative or a friend.
Speculum Exam A tool called a speculum is The exam might be uncomfortable but
inserted into your vagina. The speculum is used shouldnt hurt. The best way to deal with
to look at your vagina and cervix. The cervix is this discomfort is to take some slow deep
the opening to your uterus. Samples of vaginal or breaths. Breathe in through your nose
cervical discharge will be taken with a large Q- and blow out through your mouth. If you
tip. These samples are used to check for vaginal feel any pain during the exam, tell your
infections, STIs and cancer. provider.
Bimanual Exam Your provider will put one or If you want, ask for a mirror during the
two gloved fingers inside your vagina. He or she exam so you can see whats happening.
will then press with the other hand on the outside Be familiar with your body so you know
on your lower belly. This is to check the size when anything changes.
and position of your cervix, uterus and ovaries.
Sometimes the provider will also perform a rectal Ask questions! This is an especially great
exam and insert a finger in your anus. This is to opportunity to ask about your body, sex,
check for tumors, and is not usually done on teens. STIs and birth control.
If you dont want to be contacted at your
The provider will let you ask any questions and then
leave the room so you can change. If the results of the test
home with your test results, make sure
you speak up about this!
are normal you wont hear anything. If the results of the
tests are not normal, someone from your providers office You can call your provider to find out the
will contact you within a week. results of your tests.

For youth
What to Expect at Your First Mens Health Exam.

To make sure that you are healthy, your healthcare provider will check your genitals. This can seem uncomfortable or
embarrassing, but exams are important for your health. A provider needs to check your anatomy to make sure you are
developing normally. If you are sexually active they will check for sexually transmitted diseases. They may also check
your testicles for signs of testicular cancer, which is rare but can effect young men.
Your health care provider will ask you some questions about your
body. He or she will ask if you have noticed any changes, and if you
SOME TIPS...
It is your right to ask for a
are sexually active. It is important to tell the truth when you answer different health care provider
the questions. The provider will not tell anyone what you tell him or if you do not feel comfortable
her unless he thinks that someone has hurt or abused you. with the one you have.
You will be asked to undress and put on a gown. You will probably
be left alone in the room to change your clothes.
It is almost always ok to bring
someone, like a relative or a
friend, into the exam room
Your provider will start by looking at your genital hair. He or
she will then gently touch your testicles, penis and the surrounding
with you.
areas. He or she is looking for anything that looks or feels unusual. The exam might be
Your provider may also teach you how to give yourself a testicular uncomfortable but it shouldnt
exam hurt. If you feel any pain
during the exam, tell your
You may be asked to turn your head and cough. This is to
check for hernias.
provider.
Be familiar with your body
Your provider might perform a rectal exam. This is done by

inserting a gloved finger in your anus. This is not usually performed
so you know when anything
changes.
on teens. Ask questions! This is a great
opportunity to ask about your
Your provider may test for sexually transmitted infections. He
or she will test you if you are sexually active or if you have STI
body, sex, STIs and birth
control.
symptoms. You can also ask for STI tests. This may be done by
asking you to pee in a cup. Sometimes this is done by inserting a Q- If you dont want to be
tip into the small hole at the tip of your penis, the urethra and in the contacted at your home with
anus if you have anal sex. If you are worried about the Q-tip exam, your test results, make sure
ask if they offer a urine test when you schedule the appointment. you speak up about this!
You can call your provider
Your provider will usually leave the room so you can change.
Ask your provider any questions about the exam and your health.
to find out the results of your
tests.
Other Resources/Links:
Sexual Health Exams
http://www.youthresource.com/health/features/what_to_expect.htm
http://www.youngmenshealthsite.org
http://www.teenwire.com/infocus/2003/if-20031015p199-gyno.php
Self-Testicular Exams
http://www.kidshealth.com/teen/sexual_health/guys/tse.htm
http://www.usrf.org/video_tomgreen/tcexam.html

For Youth
Your Safer Sex Options:

Preventing Pregnancy & Protecting Against STIs
Depo-provera (the hormonal injection) and the IUD are the most effective types of birth control.
It is best to use condoms and another method that protects against pregnancy (birth control pills, IUD, depo-
provera, etc.).
Condoms come in many shapes, sizes, colors, flavors and varieties. Try a different shapes or styles if a condom
feels uncomfortable. Check out condomania.com for different options.
New birth control products come out all the time. To learn about new methods, ask your health care provider.
METHOD HOW IT WORKS PROS CONS

Male Condom Piece of plastic/rubber
86-97% effective Protects against STIs (latex are You have to be prepared. A
covers penis and stops
the best) and pregnancy. Dont new one is needed after every
cum from entering vagina
need a prescription. act of sexual intercourse.
or anus.
Female Condom Provides protection against

Piece of plastic shaped
79-95% effective STIs and pregnancy. Can
like a sock that goes in Condom can be noisy or feel
be use by people with latex
the vagina or anus and uncomfortable.
allergies. Dont need a
stops cum from entering.
prescription.
Cervical Cap Rubber cup that covers No protection against STI and
82-94% effective
the opening to the womb Can put it in several hours has to be fit by a health care
or uterus and blocks before sexual intercourse. provider. It can cost a lot
sperm. without insurance.
Diaphragm Dont have to take it out

80-94% effective Dome shaped rubber cup between acts of sexual No protection against STIs
that covers the cervix and intercourse. Works for about and can be messy or awkward
blocks sperm. 6 hours, but need to reapply to use.
spermicide.
Spermicides
74-85% effective Gel that is put in vagina
Its messy. Not the best
before intercourse and Dont need a prescription.
protection against STIs.
kills the sperm.
Injection (Depo-Provera)
99% effective Cant see it. You dont have to No STI protection and need
A hormone shot taken worry about birth control for 3 to go to see a provider every
every 3 months months once you get the shot. 3 months for next shot. Can
Can stop periods. stop periods.
Oral Contraceptives
(Birth Control Pills) Hormone pills taken 24/7 protection. Can make Need to remember or remind
95-99% effective everyday that stops periods lighter and more your partner to take the pill
release of egg from ovary regular everyday. No STI protection.

For youth
Your Safer Sex Options cont.

METHOD HOW IT WORKS PROS CONS
Vaginal Ring (Nuva Ring) Plastic ring thats put No protection against STIs.
99% effective inside the vagina and left Cant see it. You only have Have to feel comfortable
in for three weeks. A new to insert and remove it once a putting in and taking out the
ring is reinserted 1 week month. ring or help your partner put
later. it in and take it out.
Birth Control Patch A patch that is worn on No protection against STIs.
(Ortho Evra) the skin in a certain area Does not require taking a pill. Must change it every week.
99% effective that must be changed Can be hidden by clothing. Can cause side effects like
every week. breast tenderness and nausea.
Hormonal Implant
(Implanon) A small tube with
Barely visible and works for 3 No protection against STIs.
99% effective hormones is inserted in
years. Can cause irregular periods.
the womens upper arm.
Emergency Hormone pills taken 3-5

Contraception days after unprotected Not a regular form of birth
75-88% sex. Stops ovulation or Can be taken after intercourse. control. Does not protect
effective prevents egg from being against STIs.
fertilized.
Intra-Uterine Device No protection against STIs.
(IUD) Hormonal IUD is good for 5
A plastic device is put in Risk of serious infection
97-99% years. The copper IUD is good
the womans uterus. shortly after insertion. Can
effective for 10 years.
make your periods irregular.
Withdrawal During intercourse, the Pulling out in time can be

81-96% effective
man pulls his penis out of Is natural and no supplies are difficult to predict. Pre-
the vagina or anus before needed. ejaculation fluids can transfer
he cums. HIV and other STIs.
Abstinence Requires motivation, self-

100% effective control and communication
A couple does not have Only definite way to prevent
from both partners. Only
sex. pregnancy and STIs.
works if it is used 100% of
the time.
FOR MORE INFORMATION ON ANY OF THESE METHODS, CHECK OUT THESE WEBSITES:
Young Womens Health:
http://www.youngwomenshealth.org/contra.html
Teen Talk
http://www.plannedparenthood.org/teen-talk/birth-control-25029.htm

For Youth
A Teens Guide to Sexually Transmitted Diseases and Other

Infections
Infection What are the symptoms? How is it spread? Is it curable?
Most often there are NO
SYMPTOMS. Yellowish Yes, but it must be treated to
Chlamydia discharge, burning with Through unprotected prevent Pelvic Inflammatory
Bacterial urination, bleeding between vaginal, oral, or anal sex. Disease (PID), or damage to
periods, swollen or tender the reproductive organs.
testicles.
Most often there are NO Yes, but it must be treated
Gonorrhea SYMPTOMS in women. Through unprotected to prevent other problems,
Bacterial Yellowish discharge, burning vaginal, oral, or anal sex. like PID, or damage to the
with urination, stomach pain. reproductive organs.
By touching an infected No. Herpes is treatable,
area (which may not be but does not go away.
Genital Herpes Blister-like sores in the
noticeable), or having People with herpes can be
Viral genital region or mouth.
unprotected vaginal, oral, contagious even if they are
or anal sex. not having an outbreak.
No. HPV is treatable but
By touching or rubbing
One type of HPV causes does not go away. The most
Human Papillomavirus genital warts. Another type an infected area (which
common types of HPV can
(HPV or Genital Warts) can cause cervical and anal may not be noticeable), or
be prevented by a vaccination
Viral having unprotected vaginal,
cancer. of three doses. Make sure
oral, or anal sex.
youre up to date!
Through any direct
Yes. Clothes and bedding
Pubic Lice (Crabs) Severe itching, small red physical contact and rarely
must also be cleaned to get
Parasite bumps. through indirect contact
rid of the bugs.
such as a shared object.
Most often there are NO
SYMPTOMS in men.
Itching, irritation, redness,
Trichomoniasis Through unprotected
discharge, bad smell, Yes.
Parasite vaginal sex.
frequent and/or painful
urination, discomfort during
intercourse, stomach pain.
First stage: painless open
sore on the penis, vagina,
Through unprotected
or mouth. Second stage:
vaginal, oral, or anal sex,
Syphilis rash, fever, swollen lymph
and also through kissing Yes.
Bacterial glands, sore throat, muscle
if there is a lesion on the
aches. Final stage: damaged
mouth.
internal organs and central
nervous system.

For youth
A Teens Guide to Sexually Transmitted Diseases and Other

Infections cont.
Infection What are the symptoms? How is it spread? Is it curable?
Does not cause a long-term
Poor appetite, nausea/
Through oral contact with infection, but symptoms can
vomiting, headaches, fever,
feces. Through unprotected last 6-9 months. Once you
Hepatitis A jaundice (yellow skin), dark
anal/oral sex, drinking have had Hepatitis A you
Viral urine, light-colored bowel
contaminated water or cannot get it again. It can be
movements. Sometimes
eating contaminated food. prevented by two doses of a
there are no symptoms.
Hepatitis A vaccine.
Poor appetite, nausea/ Through unprotected
No highly successful
vomiting, headaches, fever, vaginal, oral, and anal
treatment, but can be
Hepatitis B jaundice (yellow skin), dark sex and through sharing
prevented by a Hepatitis B
Viral urine, light-colored bowel dirty needles. It is spread
vaccination of three doses.
movements. Sometimes by blood, semen, vaginal
Make sure youre up to date!
there are no symptoms. secretions and breast milk.
Weight loss, fatigue, night Through unprotected No. Although there are
sweats/fever, dry cough, vaginal, oral, and anal sex, many treatments which have
HIV/AIDS diarrhea, swollen glands, and dirty needles. Can also greatly improved the health
Viral memory loss/confusion, pass from mother to child and survival of people with
depression. Sometimes there during pregnancy or child HIV. No proven vaccine at
are no symptoms. birth, or breast-feeding. the current time.
Fishy or unpleasant vaginal
The cause of BV is not Yes, but it must be treated
odor, milky-white or gray
Bacterial Vaginosis completely understood. to prevent increased risk
vaginal discharge, vaginal
(BV) Having multiple sex of other pelvic illnesses or
itching and burning.
Bacterial partners and douching chance of having problems
Sometimes there are no
increases your risk. with a pregnancy.
symptoms.
Thick curd-like vaginal
Through an imbalance of
Vaginal Yeast discharge (like cottage
the healthy organisms in
Infection cheese), vaginal itching Yes.
the vagina. May occur
Fungal Overgrowth and burning, redness and
while on antibiotics.
irritation.
Burning or pain during
Through bacteria coming in
Urinary Tract urination, urge to urinate
close contact to the vulva Yes, it must be treated to
Infection (UTI) frequently or after youve
or urethra. It can also be prevent kidney infection.
Bacterial just urinated, fever, lower
caused by an STI.
abdominal or back pain.
From http://www.iwannaknow.org, http://www.mtv.com/onair/ffyr/protect/guide.pdf, http://www.youngwomenshealth.org, http://plannedparenthood.org/teen-talk.

For Youth
Genital Warts and HPV-Related Cancer

What is HPV?
Human Papillomavirus (HPV) is a common virus that
infects men and women. It is passed through sexual
contact. HPV can be prevented
The body usually fights off HPV before it causes any
health problems. by getting vaccinated.
There are two types of the virus: wart-causing HPV
and cancer-causing HPV. You can get one or both.
Using condoms helps
Cancer-causing HPV can cause cervical cancer in
women and anal cancer in both men and women.
prevent HPV but not
Warts caused by HPV may look like bumps of varying 100%.
shapes and colors. The warts may disappear or return.
How can I prevent HPV and its effects?

There are vaccines that can prevent some of the
At least 50% of common types of HPV. They are approved for both
men and women. Ask your provider about it.
sexually active men and Using condoms and other latex barriers every
women will be infected time you have sex helps lower chances of HPV
exposure.
with HPV. Women over 21 should get regular pap tests to
check for cervical cancer. If youre 21 talk to your
provider about getting a pap test.
If you have HPV, smoking can increase your risk
of developing cervical cancer.
I might have HPV. What now?

If you have what look like genital warts, get checked
by your provider. If you have warts, your provider
can recommend treatments to remove them from your Ask your provider for
genital area. DO NOT TRY TO REMOVE THEM BY
YOURSELF! more information on how
If you have one type of HPV you can still get other types.
Keep using condoms to lower your chance of getting you can prevent or treat
other types of HPV.
Many people who have HPV want to know who gave
HPV.
it to them. There is no way to know for sure unless a
person has had only 1 sexual partner.

For youth
What You Need To Know About Condoms...

How to Put on a Condom
Before having sex
Discuss using condoms with your partner
Buy latex or polyurethane condom
Check the expiration date. Do not use an expired condom!
Open condom package carefully. Dont use your teeth.
When the penis is erect

Squeeze the air out of the tip of the condom and place rolled condom on the tip of the
penis or dildo. If you use lube, add a couple drops of water-based lube inside the tip
of the condom.
Leave a half inch space at the tip of the condom to collect semen.
Hold the tip of the condom and unroll it until the penis or dildo is completely
covered.
Smooth out the air bubbles and put more lube on the outside of the condom after
putting it on.
After Ejaculation and when the penis is still erect

Hold the condom at the base of the penis.
Carefully remove the condom without spilling any semen.
Wrap up the condom in tissue and throw it away. (Dont flush condoms down the toilet
- the toilet might clog.)
Use a new condom every 20 minutes or for every act of vaginal, oral, and anal
intercourse from start to finish.
Condom Talk
Talking about condoms can be a lot harder than learning how to use a condom. Here are some tips on how to
bring up condoms with your partner:
Dont be shy. Be direct about your feelings. Theres no reason to be embarrassed!
Dont wait until the heat of the moment to bring it up. Talk about condom use before you are in a situation
where you might need one.
Dont be afraid of rejection. If a partner doesnt care enough about you to use a condom and protect your
health, then she or he probably isnt worth your time. As 18-year-old Ari says, If your partner turns
condom use into a trust issue instead of a health issue, why would you want to have sex with that person
anyway?
Be positive! Many people find sex more enjoyable when theyre protected because they dont have to worry
about pregnancy and infections.
Talking about condom use is easier if you are in a healthy relationship that makes you feel good about
yourself. And it gets easier with time, as well. But no matter what, its very important to communicate with
partners about condoms. Its all about protecting your health!
Reprinted with permission from Planned Parenthood Federation of America, Inc. 2009 PPFA. All rights reserved.
How to Put on a Condom, adapted with permission from Advocates for Youth, Washington, DC. www.advocatesforyouth.org

For Youth
What You Need To Know About Female AKA Insertive Condoms

How to Use a Female Condom
Before having sex

Talk to your partner about using a condom.
Buy a female condom.
Check the expiration date. Do not use an expired
one!
Carefully tear at the top right of the package. Never
use scissors or your teeth.
When you are wet

Get into a comfortable position: sit, squat, lie down or raise one leg.
Add extra lubrication inside condom so it will stay in place during sex.
Grab the inner floating ring and squeeze it with the thumb and pointer finger.
Take one hand and spread out the lips of your vagina.
Put the pointer finger of your other hand in the condom
push the inner ring in your vagina as far as it will go.
You can also use a sex toy to insert the condom.
Make sure the condom is not twisted. The outer ring
should be sticking outside of the vagina.
Hold onto the outer ring while having sex to make sure
the condom doesnt get pushed into the vagina.
After sex while you are lying down

Twist the outer ring and carefully pull it out.
Put it in the wrapper and throw away, but dont flush
toilet will get clogged.
Use a new condom for every act of vaginal and anal
intercourse.
A word about the Female Condom...

Is also called the insertive condom because it is used internally.
Can be used in the anus. The ring can be taken out or left in for prostate stimulation.
Can be used by people with latex allergies because it is made out of polyurethane.
During vaginal sex, the outside ring rubs against the clitoris. This can make having an orgasm easier.

For youth
Do I Need a period Every Month?

Sometimes, your period can come at the worst times, like before a sporting event, party, or night out with your boyfriend/
girlfriend. For years, women have used birth control pills to stop their periods for important events and vacations.
Most forms of hormonal birth control (the pill, patch or ring) can be used to stop a womens period, but it is VERY
IMPORTANT that you talk with your healthcare provider before making any changes in the way you use your birth control.
There are even brands of birth control pills packaged to take for 3 months or even a year without having a period. For
more information about stopping your periods, talk to your health care provider.
Do I have to bleed every month?

There is no evidence that shows women
need to bleed monthly. Studies have found
that using the pill for two or more cycles in
a row without taking the sugar pills is safe
and effective. It prevents pregnancy just as
What are the benefits of well as taking the pill in the usual way.
Skipping your period?
Less pain with monthly bleeding
Less heavy bleeding
Fewer PMS symptoms
Reduced menstrual migraines and acne
An increased feeling of well-being
What are the side effects or

Disadvantages of skipping your period?
Some women have breakthrough bleeding or spotting in
the first few months. This is less common once your body
has gotten used to the new routine. Blood from spotting
may be dark brown from being in the uterus longer.
Just like when you take pills in the usual way, you should
contact a health care provider if you experience ACHES
Abdominal pain, Chest pain, Heavy bleeding, Eyesight or vision
changes, or Severe leg pain.
Adapted with permission from ARHP Health Matters Fact Sheet: Understanding Menstrual Suppression

For Youth
IM PREGNANT, WHAT SHOULD I DO?

Choosing what to do when you are pregnant is difficult and none of the options is the easy or right choice. Each
choice comes with its own set of challenges. Consider all your options and how each one will fit with your life and
beliefs. When possible, talk this over with your parent(s) or another trusted adult. Your health care provider can also
assist you in learning about and discussing your options.
WHAT ARE YOUR CHOICES?

1. Parenting
Being a parent is a hard job for anyone. It can be even harder if you are a
RESOURCES
For even more information about
young parent. It is a 24-7 responsibility for at least 18 years. These questions
your options and the experiences
may help you think about whether or not you want to be a parent at this time
of other teens who have gotten
in your life:
pregnant, visit or call:
Where will you live?
Stay Teen
What will you do about money? How will you support yourself and
http://www.stayteen.org/
your child?
What will you do about school? Planned Parenthood
http://www.plannedparenthood.
Who will provide childcare while you are at work or school?
org/teen-talk/
What do you want out of life for yourself? What do you think is 800-230-PLAN
important?
What are your goals and how will you meet them? (a college degree, Sex, Etc.
a job, a family?) http://www.sexetc.org/
How will having a baby change your social life?
How will the babys father be involved in your pregnancy and
parenting?
Safe Haven Laws
2. Abortion
The Safely Surrendered Baby Law
If you are not ready to be a parent or go through a pregnancy, abortion might
lets you confidentially give up you
be something to consider. An abortion is a medical procedure that ends a
baby. The baby must be 72 hours
pregnancy. Your health care provider can tell you the names of providers and
old or younger. As long as the baby
clinics that are covered
has not been hurt, parents may give
by your insurance plan.
up their newborn and not get in
You can also call Planned
trouble or arrested.
Parenthood to discuss this
option further or visit their http://www.nationalsafehavenalliance.org
website (see the resources
box above).
If you have had an abortion, you may consider calling Exhale, a
counseling service for women who have experienced abortions, at
1-866-4-EXHALE. Visit their website at www.4exhale.org.
3. Adoption
Adoption is another choice if you do not want an abortion but are
not ready to become a parent. There are a lot of different types of
adoption. In an open adoption, you know who the adoptive parents
are. In a closed adoption, you do not know who they are. For more
information about adoption, call the National Council for Adoption
Image reproduced with permission by Pro-Choice Public Educa-
tion Project. Copyright 2005
hotline, 1-866-21-ADOPT. Also check out http://www.childwelfare.
gov/adoption/ for more information and resources.

For Parents
How to Talk with Your Children and Teens about
Talk to your children and teens about friendship, dating, and love before they start to ask
questions about these important issues.
Listen to your children and teens and try to understand their point of view.
If you cant answer a question, help your children talk to other trusted adults.
Use daily experiences like watching TV, to talk with your children and teens. It is a chance to
share your values and messages with them.
Find out what schools are teaching your children and teens about
these topics.
Stay active in the lives of your children and teens and help them
plan for the future.
Know and practice the messages that you want to share with your children
and teens.
Use the information below to make your messages clear.
Message Information For Ages 12-15:

Friends can influence each other in positive and negative ways.
People can be friends without being sexual.
People are ready to start dating at different times.
When couples spend a lot of time together alone, they are more likely to become sexually involved.
If someone pays for a date or gives gifts, it does not mean that they are owed sexual activity.
In a love relationship, people help each other to grow as individuals.
People may mix up love with other strong emotions like jealousy and control.
Message Information For Ages 15-18:

Dating can be a way to learn about other people and what it is like to be in a love relationship. It is
also a way to learn about romantic and sexual feelings.
Being honest and open can make a relationship better.
Both people in the relationship are responsible for it.
A dating partner cannot meet all of the needs of another person.
A lot of time, love changes during a long term relationship.
Keep these talks going! When you talk about relationships with your teen, you can hear about what is
going on in your teens life. You can also teach your teen about your familys values and beliefs.
Adapted from SEICUS. Families Are Talking; Volume 3, Number 1, 2004.

For Parents
Should I Worry About My Teen?
The Facts about Teen Dating Violence:
Teen dating violence is when a teen:
Hits, punches, slaps, or kicks their partner.
Forces or pressures their partner to have sex.
Teases, controls, or intimidates their partner.
Isolates their partner from friends and family.
Stops their partner from doing normal activities.
Warning signs for Teen Dating Violence

Know the warning signs of when a teen is being abused or is abusing others. Ask yourself the following
questions:
Has your teen or your teens dating partner
Lost interest in activities that used to be enjoyable?
Stopped hanging out, talking on the phone, or staying in contact with friends?
Acted extremely jealous?
Violently lost their temper and hit or broke objects?
Tried to control their partners behavior?
Check up constantly on their partner and demand to know who their partner is with?
Had a sudden change in weight, appearance, or school performance?
Had injuries that cannot be explained, or gave an explanation that did not make sense?
If you notice any of the above warning signs, talk with your teen about his/her
relationship. Try and stay supportive and non-judgmental. Contact a domestic
violence agency or call 1-800-799-SAFE for advice on the situation.
Did you know there are ways to prevent teen dating violence? Here are
some of the things that help:
Talk to your teen about their friends and relationships.
Listen to your teen and be open to their experiences.
Support your teen in pursuing their interests.
Help your teen get involved in school and after school programs such as clubs and sports.
Encourage your teen to join religious, spiritual, or community groups.
Assist your teen with volunteering in the community.
Source:
Liz Claiborne, Inc, National Teen Dating Violence Helpline, Love Is Respect.org: A Parents Guide to Dating Violence: Questions to Start the Conversation.

For Parents
Parent-Child Communication
Many parents freeze when they are faced with talking to their children about sex.1 Many teens prefer to talk
to their parents rather than doctors about sex. It can feel awkward, but you can help your child make healthy
choices. They need you, and if you are not talking to them, somebody else will. Think about what you want
them to know.
Why should you talk to your child about sex?

Teens who feel connected to their home and families wait to have sex.2
Teens whose parents talk to them about condoms are more likely to use them.3
Teens who said they talked to their parents about sex are more likely to use contraception.4
Teens who have talks with their parents about sex are more likely to have talks with their partners
about sex.5
Teens whose parent talk to them about their sexual orientation have lower risk for STIs, including
HIV.6
Its not just what you say, but how you say it. Healthy communication
means:
Openness to all topics and ideas.
Each party talks and also listens.
Being warm and caring.
Trying not to fight.
Tips for Talking with Your Teen

Even if your teen does not want to talk, let them know there
is an open door if and when they do.
Many teens are afraid that they will disappoint their parents.
Praise your teens healthy choices. This may lessen these
fears.
1
The Media Project, a project of Advocates for Youth.
If your teen comes to talk to you about something, as scary Parent-Child Communication: Helping Teens Make
Healthy Decisions about Sex. 2002.
as it may be, do not run away or simply tell them not to have 2
Resnick, MD et al. Protecting Adolescents from
sex. This may be perceived as uncaring or discomfort and Harm: Findings from the National Longitudinal
Study on Adolescent Health, JAMA; 1997; 278:823-
can set the stage for how they think you will respond every 32.
time. 3
Miller, KS et al. Patterns of Condom Use Among
Adolescents: The Impact of Mother-Adolescent
Make the most of learning moments. Learning moments Communication. American Journal of Public Health
1998; 88: 1542-44.
are when something you and your child see can be used as a 4
Hacker, KA et al. Listening to Youth: Teen Perspec-
chance to start a talk. For example: tives on Pregnancy Prevention. Journal of Adolescent
Health 2000; 26: 279-88.
5
Whitaker, DJ et al. Teenage Partners Communi-
When you and your child see a sex scene in a movie or cation About Sexual Risk and Condom Use: The
on television, or when you see a sexual advertisement Importance of Parent-Teenager Discussions. Family
Planning Perspectives; 1999; 31(3): 117-21.
When a young person or adult you both know gets 6Ryan C. Supportive families, healthy children:
Helping families with lesbian, gay, bisexual & trans-
pregnant. gender children. 2009; San Francisco, CA: Marian
Wright Edelman Institute, SF State University.

For Parents
Sex, Technology & Your Teen

Technology Sexual Use Privacy Tips
E-mail Email and all attachments can be
Electronic letters that are sent with Emails can have sexual content. This widely forwarded, or sent to others.
computers or cell phones. Pictures content can either be sexual language Talk to your teen about this privacy
and other files can be attached to or attached sexual pictures.
risk.
an email.
To prevent forwarding IMs, your
Instant Message (IM) teen can set chats off the record.
Real-time messages sent back and IMs can have sexual content. This
This means no record of the
forth between two people with content can be sexual language.
conversation will be saved. Text can
computers or cell phones. still be copied and pasted.
Text Message Text messages can have sexual Your teen can send anonymous text
Short messages sent to someones content. This content can be messages through services such as
cell phone from another cell phone. sexual language or attached sexual www.anontxt.com. This will keep
Pictures can also be sent through pictures. their identity private.
text messages.
Remind your teen to keep his/her
Chat Rooms Chats can have sexual content. identity private by choosing a
A virtual room that allows people Users can also be invited to chat in a screen name. A screen name is an
to chat back and forth in real-time. private room. alias or name different from your
real name.
Social Networking Websites Your teen can control what profile
Online websites that allow users information is viewed by the public.
to build a customized profile Social networking sites can be Talk to your teen about changing
webpage. Profiles contain short used to meet people for sexual the privacy settings to limit viewers
biographical information along relationships. of their site. Remind your teen
with pictures and interests. Users not to post phone numbers or home
can become friends with other addresses publicly.
users and share information.
Text M essaging:
An Update on k e d a n d p a rtially naked
ding na US for mino
rs.
u a l te x t m e ssaging (sen le g a l in th e
Sex an be il ssages
tu re s th ro ugh texts) c re c e iv e d s e xual text me d
p ic
te e n s w h o have sent or o g ra p h y. This can lea
Some hild po rn ing
b e e n c h arged with c s s ib le ja il time or gett
ha v e school, p o e
u ls io n fr o m to y o u r te en about th
to exp der. Talk
a s a sex offen aging.
reg is te re d
c e s o f s e x u al text mess
uen
legal conseq
Chart adapted from: Subrahmanyam, Kaveri and Patricia Greenfield. 2008. Online Communication and Adolescent Relationships. The Future of Children,
18(1), 119-146.

For Parents
What Parents of Preteens/Adolescents Should

Know About the HPV Vaccine
There are now vaccines that protect against some types of the human papillomavirus (HPV). HPV
is the common virus that causes most cervical cancers and genital warts. The vaccine is a series of
three shots.
The HPV vaccine is safe for males and females

between the ages 9 to 26. The HPV vaccine is
usually given when girls are 11- or 12-years old. What Is HPV and What Are Its
Currently, one of the vaccines is optional for boys. Health Effects?
It is best to get vaccinated before becoming HPV is passed on during sex. There are
sexually active. This vaccine works best in girls/ about 40 types of HPV that can infect the
women who have not been exposed to HPV. genital areas of men and women. Most
sexually active adults get HPV at some time
The vaccine work against certain types of HPV. in their lives. Most never know it because
It is nearly 100% effective in girls/women who have HPV usually has no symptoms and goes
not been infected with any of those types of HPV. It away on its own. But:
works by preventing precancers of the cervix, vulva,
and vagina. It also prevents genital warts. Some types of HPV can cause cervical
cancer in women.
The vaccine is a series of three shots over a
six-month period. It is very important that she/he
Other types of HPV can cause genital
receive all three shots. It is not yet known how much warts.
protection she would get from receiving only one or
two shots of the vaccine.
The vaccine causes no serious side effects. The

most common side effect is soreness where the shot
was given.
The HPV vaccine costs about $120 per dose

($360 for the series). You may be able to get
it for free or at low-cost. Check with your health
insurance plan or federal or state programs. The
vaccine is free through the Vaccines for Children
(VFC) program. You can also get more information
about these programs at your providers office or the
local health department.
Adapted with permission from What Parents of Preteens/Adolescents Should Know About the HPV Vaccine, CDC.

For Parents
Supporting Your Pregnant and Parenting Teen

Finding out that your child is pregnant or made someone pregnant can cause you to feel a wide range of emotions. If
your teen has made the decision to become a parent, the following tips raise considerations to help you and your family
through the challenges that lie ahead.
It is normal to feel angry, disappointed and
overwhelmed. Just remember that your teenager needs
you now more than ever. Being able to communicate with
each other especially when emotions are running high
is essential to the health of your teen.
Explore resources available to your son or

daughter and your family.
Stay involved with the pregnant teens medical

treatment. The earlier your teen gets prenatal care, the
better her chances are for a healthy pregnancy.
When the baby is born, remember you are the

grandparent to that child, not the parent. This
may be especially difficult if they live with you, but it is
important to support your son or daughter in parenting the
newborn. Image reproduced with permission by Pro-Choice Public Education Project.
Copyright 2005
Help financially if you are able to, but also remember that as a parent, you are not financially
responsible for the child. Encourage your son or daughter to find a part-time job and be as financially
responsible for the child as possible. This is sometimes very difficult for a full-time student and parent, but in the
long run it will be best for the new family.
Communicate with your other children early about sexuality, pregnancy and STIs. Sisters of
teenage parents are more likely to become pregnant at a young age.
Find someone outside the situation that you can talk to. This is a difficult situation, and you will be a
better parent and grandparent if you have your own support system for handling the issues involved.
SUPPORTING YOUR TEEN DAUGHTER SUPPORTING YOUR TEEN SON

Keep in mind that this is the pregnant teens decision. Support him in taking responsibility for his
Do your best to respect the decisions that she makes. actions, both financially and emotionally.
Encourage the involvement of the babys father and Encourage your son to take interest in the
his family. pregnancy. Encourage your son to be available
for appointments and read about pregnancy.
If your daughter decides to continue the pregnancy, Encourage him to also set aside time for the
encourage and help her to stay in school so that she weeks leading up to the birth.
can secure a better job and create a better life for
herself and the baby. Go to the school and assist your Encourage your son to understand his legal rights
daughter if there are school related issues. Explore and responsibilities surrounding fatherhood.
school and community programs that offer special
services for teen mothers, such as child care, rides,
or tutoring.

internet resources: Click on This!
Young Womens Health
GENERAL SEXUAL HEALTH www.youngwomenshealth.org
Association of Reproductive Health Professionals
(ARHP), www.arhp.org/ Comprehensive website addressing female sexual
and general health issues.
Contains information on many sexual health
topics. Also has a section on adolescent sexual Young Mens Health
health. www.youngmenshealthsite.org
Go Ask Alice Comprehensive website addressing male sexual
www.goaskalice.columbia.edu and general health issues.
Provides extensive information on sexual health
and relationships.
Kaiser Family Foundation (KFF)
www.kff.org
Contains general health information and also
provides fact sheets and summaries on adolescent
sexual health.
Physicians for Reproductive Choice and Health
(PRCH)
www.prch.org
Provides information on sexual health care for
providers in the form of minor access cards, policy
statements and fact sheets.
Planned Parenthood
www.plannedparenthood.org, www.
plannedparenthood.org/teen-talk
Provides healthcare, sex education and
advocates for sexual and reproductive health. Teen-
Talk is the youth-oriented version of the site.
Scarleteen
HEALTHY RELATIONSHIPS
CDC, Healthy Relationship Website
www.scarleteen.com
http://www.cdc.gov/Features/ChooseRespect/
Provides information about sexual health
Contains fact sheets and an article on aspects
based on requests from youth.
of a healthy relationship and identifying when
Sex, Etc. intimate partner violence is taking place.
www.sexetc.org
Choose Respect
Provides informal information about sexual www.chooserespect.org
health online. They also have a large glossary on
Contains articles on building a healthy
many different sex terms.
relationship and understanding the difference
Sexuality Information and Education Council of between a healthy and unhealthy relationship.
the United States (SIECUS)
Love is Respect
www.siecus.org
www.loveisrespect.org
Provides resources for providers and youth Contains interactive quizzes, an application that
on adolescent sexuality, STIs and reproductive
allows teens to make movies on healthy relationships
health. They focus on sexual and reproductive health
and other resources on dating and violence.
research and policy analysis.
= Resource for Providers = Resource for Youth = Resource for Parents

TEEN DATING VIOLENCE CIRCUMCISION
Teen Relationships Guttmacher Institute
http://www.teenrelationships.org/ www.guttmacher.org
Provides informal resources on building a healthy Contains research articles on female circumcision
relationship in the form of quizzes and forums that and male circumcision.
provide advice. Kids Health
Break the Cycle: Empowering Youth to End www.kidshealth.org/parent/system/surgical/
Domestic Violence, www.breakthecycle.org circumcision.html
Provides domestic violence and dating violence Provides information on the pros and cons of
facts as well as information on the warning signs of male circumcision. They also provide information on
abuse. caring for circumcised and uncircumcised penises.
Family Violence Prevention Fund
www.endabuse.org/programs/teens PREGNANCY PREVENTION
Provides facts for teens and immigrant The National Campaign to Prevent Teen and
women on intimate partner violence, resource lists, Unplanned Pregnancy
and safety planning. www.thenationalcampaign.org/
Love is Not Abuse, Liz Claiborne Inc.
The National Campaign provides resources
on potentially negative adolescent sexuality outcomes
www.loveisnotabuse.com
in the form of reports and resources. They have an
Contains informative handbooks, wallet entire section of their website in Spanish.
cards, links to online resources and quizzes on teen
dating violence. Stay Teen
www.stayteen.org
National Youth Violence Prevention Resource
www.safeyouth.org Sponsored by the National Campaign to Prevent
Teen Pregnancy and offers informal information on
This sector of the CDC provides fact building self-confidence, questions to ask yourself
sheets and information on violence in English and
when falling in love and sexual decision-making.
Spanish.
The Emergency Contraception Website
SEXUAL ABUSE www.not-2-late.com
Rape Abuse and Incest National Network Information about Emergency
www.rainn.org Contraception and where to obtain it.
Provides information about sexual
assault and abuse. Find information here on domestic
violence, abuse, prevention, how to seek counseling,
legal rights, and state and local sexual assault
organizations.
SEXUAL PLEASURE AND FUNCTION

Sexuality and U: What Is Sex?
www.sexualityandu.ca/teens/what-5.aspx
This site outlines different aspects of sexuality
and sexual function.
Good Vibes
www.goodvibes.com
Toy distributor that offers educational
information about sex toys and lubricant ranging
from cleaning recommendations to how toys can best
be used for pleasure.

PREGNANCY OPTIONS STI/HIV INFORMATION
Backline Center for Disease Control (CDC)
www.yourbackline.org/ www.cdc.gov
This site provides information for pregnant Contains STI screening and treatment
women who need support making a decision to protocols, fact sheets and resources in English and
either abort or continue the pregnancy. Contains a Spanish on various sexual and reproductive health
pregnancy options workbook to assist in the decision- topics.
making process. Iwannaknow.org
Abortion Access www.iwannaknow.org
www.abortionaccess.org Provides information to youth, parents and
Abortion Access provides resources and providers about STIs.
information on challenges to accessing abortion in American College of Obstetricians and
various states. Gynecologists (ACOG), www.acog.org
Exhale Provides screening recommendations and
www.4exhale.org educational resources on sexual health for women
This is a national organization that provides and adolescent girls.
non judgmental post-abortion counseling through a American Society for Colposcopy and Cervical
nationwide, multilingual talkline. Pathology (ASCCP), www.asccp.org
Planned Parenthood Provides educational resources and materials on
www.plannedparenthood.org HPV and cervical cancer screenings for women and
Provides information of pregnancy girls.
options including details on the different types of U.S. Preventive Services Task Force (USPSTF)
abortion. http://odphp.osophs.dhhs.gov/pubs/guidecps/uspstf.
htm#USPSTF
MALE INVOLVEMENT Website for a government appointed panel that
US Dept of Health and Human Services provides recommendations on testing and screenings.
http://fatherhood.hhs.gov/ Their recommendations cover adolescent sexual
Provides a list of resources spanning from health.
pregnancy to legal services to promote responsible Adolescent AIDS
fatherhood regardless of the socioeconomic www.adolesecentaids.org
background. HIV educational materials for youth.
The National Campaign to Prevent Unplanned The Body
Pregnancy www.thebody.com
www.thenationalcampaign.org/resources/males.aspx Contains online resource for HIV/AIDS.
Contains policy briefs, and fact sheets on
the importance of male involvement in pregnancy YOUTH OF COLOR
prevention and parenting.
MySistahs
www.mysistahs.org
This site is created by and is for young women
of color. Contains information and support on sexual
and reproductive health issues.
Ambiente Joven
www.ambientejoven.org/
A bilingual web site for gay, lesbian, bisexual,
and transgender Latino/a youth. Provides resources
and other aid to an underrepresented community.

LGBT YOUTH SEXUAL HEALTH ADVOCACY
Gay, Lesbian and Straight Education Network Advocates for Youth
www.glsen.org www.advocatesforyouth.org
Provides news, resources and links Provides act sheets are in English and
aimed at promoting school and community safety and Spanish. They have a sexual education center for
respect for youth regardless of sexual orientation parents and tip sheets for providers.
or gender identity. Pro-Choice Public Education Project (PEP)
Youth Resource www.protectchoice.org/
www.youthresource.com Offers advocacy, and information on HIV-
A web site by and for gay, lesbian, bisexual, positive youth, in the form of an informal question
transgender and questioning (LGBTQ) young people, and answer section on HIV and AIDS.
takes a holistic approach to sexual health and overall Guttmacher Institute
wellness. www.guttmacher.org
OutProud Provides resources on adolescent sexual and
www.outproud.org reproductive health. They focus on sexual and
Offers tons of resources for queer youth including reproductive health research, policy analysis and
links to current relevant news headlines, support public education. The provide fact sheets in English,
groups, online brochures, literature, magazines, and Spanish and French and information on healthcare
more. policies in each state.
YOUTH WITH DISABILITIES TALKLINES AND HOTLINES

National Dissemination Center for Children with Planned Parenthood
Disabilities, www.nichcy.org 1-800-230-PLAN
A site maintained by the National Planned Parenthood Clinic locator.
Information Center for Children and Youth with Gay, Lesbian, Bisexual, Transgender (GLBT)
Disabilities to help disabled youth learn from and National Youth Talkline, GLBT National Help Center
connect with each other. 1-800-246-PRIDE
Common Thread Mon to Fri 5-9 PM (Pacific Time), English
www.commonthread.org/home.html Confidential peer counseling on coming-out issues,
Provides community and support for young relationships concerns, school problems, HIV/AIDS
adults dealing with disability or illness and their anxiety, and safer sex.
parents, siblings and friends. National Teen Dating Abuse Helpline
The Adolescent Health Transition Project 1-866-331-9474 (TTY: 1-866-331-8453)
http://depts.washington.edu/healthtr/Teens/intro.htm 24/7, English
Provides information and resources to help Free and confidential helpline and online chat room
adolescents with special health care needs, chronic for teens (13 to 18 years old) who experience dating
illness, physical and developmental disabilities violence or abuse.
become informed participants in their health care. RAINN: Rape, Abuse & Incest National Network
Sexual Health Network 1-800- 656- HOPE
www.sexualhealth.com/channel/view/disability- 24/7, English and other languages
illness/ Connects callers to their nearest rape crisis center to
Provides information on how sexual health speak with a counselor.
is impacted by a variety of disabilities both National AIDS Hotline
developmental and physical. 1-800-342-AIDS (Spanish: 1-800-344-SIDA)
24/7, English; 8AM-2AM, Spanish
Information and referrals to local hotlines, testing
centers, and counseling

Adolescent Health Working Group, 2010

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Sexual Health

An Adolescent Provider Toolkit

Illustrations by Jordan Zioni, 17

Erica Monasterio, MN, FNP

The Adolescent Provider Toolkit Advisory Council

Youth Focus Group Participants

Financial Supporters/Fiscal Sponsor

2. Screening, Assessment, Taking a Client-Centered Sexual History............................................................................C-13

B. FOR YOUTH Sex, Virginity & Abstinence................................................................................................C-45

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

STAGE FACTS TIPS

Increasing concern with appearance. Listen more and talk less.

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

When considering the stages of development, be sure to.

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

TIPS FOR TALKING TO TEENS

Begin by discussing confidentiality and its limits. This helps

Negotiate the agenda. Make an effort to address the issue(s) that

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

The basic framework for Motivational Interviewing is as follows:

1. ASK PERMISSION to engage in the topic of discussion.

3. RESPOND TO PATIENTS READINESS

4. KEEP FRAMES IN MIND when counseling for behavior change

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

LEARN THE MINOR CONSENT AND CONFIDENTIALITY LAWS IN YOUR

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

DISCUSSING HEALTHY RELATIONSHIPS WITH ADOLESCENTS:

3. How do you handle a disagreement in your

MESSAGES FOR HEALTHY RELATIONSHIPS

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

THEMES INFLUENCING ADOLESCENT SEXUAL-

MALE INVOLVEMENT IN PREGNANCY PLANNING

. Understand that he is in control regarding when and how his sperm is

Adolescent Provider Toolkit C-11 Adolescent Health Working Group, 2010

ADDITIONAL STEPS PROVIDERS CAN TAKE INCLUDE:

MALE INVOLVEMENT IN PARENTING

Tips For Encouraging Male Involvement:

Approach young men as partners and assets rather than adversaries.

Adolescent Provider Toolkit C-12 Adolescent Health Working Group, 2010

Guidelines For Sexual History Taking

Adolescent Provider Toolkit C-13 Adolescent Health Working Group, 2010

*Ask every adolescent patient regardless of sexual activity.

Adolescent Provider Toolkit C-14 Adolescent Health Working Group, 2010

SEXUAL ASSAULT AND RELATIONSHIP VIOLENCE

EXPEDITED PARTNER THERAPY (EPT) AND PARTNER NOTIFICATION

Adolescent Provider Toolkit C-17 Adolescent Health Working Group, 2010

TO COUNSEL OR NOT TO COUNSEL?

Adolescent Provider Toolkit C-18 Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C-19 Adolescent Health Working Group, 2010

WHEN TO START SCREENING FOR CERVICAL CANCER1,2:

Adolescent Provider Toolkit C-20 Adolescent Health Working Group, 2010

RECOMMENDATIONS FOR ADOLESCENTS

Adolescent Provider Toolkit C-21 Adolescent Health Working Group, 2010

IS THE INTRAUTERINE DEVICE (IUD) AN OPTION FOR YOUTH?

The following are NOT IUD contraindications:

Adolescent Provider Toolkit C-22 Adolescent Health Working Group, 2010

Ortho Evra and the birth control patch

QUICK START ALGORITHM

Adolescent Provider Toolkit C-23 Adolescent Health Working Group, 2010

Quick Start Algorithm

1. Pill, Patch, Ring, Injection

First day of last menstrual period (LMP) is:

5 days ago >5 days ago

2. Screening, Assessment, Taking a Client-Centered Sexual History............................................................................C-13

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

Adolescent Provider Toolkit C- Adolescent Health Working Group, 2010

. Understand that he is in control regarding when and how his sperm is